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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


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littp://www.arcliive.org/details/diseasesofeyetlieOObuffiala 


THE 


DISEASES  OE  THE  EYE 


MEDICAL    AND    SURGICAL    TREATMENT. 


BY 


J.  H.  BUFFUM,  M.D.,  O.  et.  A.  Chir., 

PROFESSOR  OF  OPHTHALMOLOGY  AND  OTOLOGY  IN  THE  CHICAGO  HOMCEOPATHIC 
MEDICAL    COLLEGE;   OPHTHALMIC    SURGEON    TO  THE   CENTRAL  DI8PEN- 
SARV;    FORMERLY    RESIDENT  SURGEON  OF  THE    NEW    YORK  OPH- 
THALMIC HOSPITAL  ;  MEMBER  OF  THE  AMERICAN  INSTITUTE 
OF    HOMOEOPATHY;    MEMBER    OF     THE     AMERICAN 
HOMCEOPATHIC    OPHTHALMOLOGICAL     AND 
OTOLOGICAL    SOCIETY,    ETC.,    ETC 


ONE   HUNDRED   AND    FIFTY    WOOD   ENGRAVINGS  AND 
TWENTY-FIVE    COLORED    LITHOGRAPHS. 


F.  F.  JACKSON.  M,  D. 

g79  W.  V»r  Burm  St. 

CHICAOa 


CHICAGO: 
GROSS    AND    DELBRIDGE. 

1884. 


CoraaaHT,  1883, 
By  gross  &  DELBKIDOE. 


K.  B.  McCabe  &  Co.,  Printeks,  Chicago. 


100 


TO 

Timothy  F.  Allen,  A.M.,  M.D., 

TR07ES30B  OP  MATERIA  MEDICA  AND  THERAPEUTICS  IN  THE  NEW  TOBK 
HOMCEOPATHIO   MEDICAL   COLLEGE, 

THIS  BOOK 

IS     DEDICATED, 

tn  sratef  ul  recognition  of  his  masterly  teachings,  of  his  valuable  contributions 

to  Medical  Science  and  Ophthalmic  Therapeutics,  and  In 

remembrance  of  many  acts  of  kindness. 


PREFACE 


In  the  preparation  of  this  work  it  has  been  the  design  of  the 
Author  to  state  as  concisely  and  briefly  as  possible  the  present  views 
of  ophthalmic  science.  The  endeavor  has  been  to  make  the  work 
practical  and  at  the  same  time  as  thorough  as  the  importance 
of  the  subject  demands.  The  causes,  symptoms,  differential 
diagnosis,  and  treatment  of  those  diseases  which  are  more  commonly 
met  with  in  general  practice  have  been  fully  considered.  The 
methods  of  treatment  described  are  those  which  have  borne  the  test 
of  hospital  and  private  practice,  and  in  the  experience  of  the  writer 
have  been  found  of  value. 

Numerous  illustrations  have  beeu  introduced  to  better  elucidate 
the  conditions  and  operations  described,  and  such  as  are  not  original 
ha^ie  been  selected  from  the  standard  works  on  ophthalmology, 
as  well  illustrating  the  points  presented.  Colored  lithographs  from 
the  admirable  atlas  of  Sichel  and  others  have  been  added  in  the 
endeavor  to  more  fully  depict  the  diseases  described  and  thus  enable 
the  student  or  practitioner  to  readily  diagnose  the  various  affections 
when  presented. 

The  brevity  of  the  book  has  prevented  reference  in  the  body  of 
the  work  to  the  authorities  consulted  in  its  preparation,  and  a  list  has 
been  appended. 

A  sheet  of  test  tj-pes  after  the  models  of  Snellen  is  furnished  for 
the  purpose  of  testing  and  recording  the  condition  of  the  vision  of 
patients. 

I  desire  to  express  my  thanks  to  Dr.  C.  F.  Bassett  for  assistance 
rendered  in  the  preparation  of  the  Index  and  the  reading  of  proof. 

90   Washington  Street, 

Chicago,  Septembeb,  1883. 


CONTENTS 


CHAPTEE    I. 
GENERAL   ANATOMY  AND   PHYSIOLOGY   OF   THE  EYE. 

PAGE. 

Anatomy  —  Physiology  —  Accommodation  —  Visual  Purple  —  Binocular 

Vision,  ..--...-  1-19 


CHAPTER    IL 
LIETHODS  OF  EXAIVONATION. 

General  Examination — Detailed  Examination — Test  for  Color — Field  of 
Vision — Testing  the  Acuteness  of  Vision — Range  of  Accommodation 
—  Focal  Illumination  -^  Examination  with  the  Ophthalmoscope  — 
Kinds  of  Ophthalmoscope  —  Use  of  the  Ophthalmoscope — Ophthal- 
moscopic Appearances  of  the  Normal  Fundus  —  Keratoscopy,     -       19-41 

CHAPTER     IIL 
GENERAL  CONSIDERATIONS  OF  TREATMENT. 

Use  of  Anaesthetics — Bandaging — Eye  Shades  —  Hot  and  Cold  Applica- 
tions— Cleansing  the  Eye — Mydriatics  and  Myopics — Instruments,    41-50 

CHAPTER    IV. 
WOUNDS  AND  INJURIES  OF  THE  EYE. 

Injuries  of  the  Orbit  —  Lids  —  Lachrymal  Apparatus  —  Conjunctiva — 
Cornea — Sclera — Iris — Lens — Vitreous — Choroid — Retina,      -        -   50-64 


"Vlll  CONTENTS. 

CHAPTER    V. 
ERRORS  OF  REFRACTION. 

PAOE. 

Kefraction — Emmetropia  and  Ametropia— Spectacles — Range  of  Accom- 
modation —  Presbyopia  —  Hypermetropia  —  Hyperopia  —  Myopia — 
Astigmatism  —  Anisometropia,        -  .  .  .  .    64-101 

CHAPTER  VL 
AFFECTIONS  OF  THE  IVITJSCLES. 

Anatomy  —  Diplopia  —  Paralysis  of  the  Ocular  Mnscles  —  Mnscnlar 
Asthenopia — Strabismus — Nystagmus,  ...  101-130 

CHAPTER    VII. 
DISEASES  OF  THE  ORBIT. 

Anatomy — Orbital  Cellulitis  —  Periostitis  —  Caries  and  Necrosis — Capsu- 
litis—Exophthalmic  Goitre — Tumors  of  the  Orbit — Diseases  of  the 
Cavities  Surrounding  the  Orbit,    .....    130-150 

CHAPTER   VIIL 
DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Anatomy  —  Dacryo-adenitis  —  Lachrymal   Strictures  —  Dacryo-cystitis — 

Dacryo-cysto-blennorrhota,  -  ...  .  .       160-167 

CHAPTER    IX. 
DISEASES  OF  THE  LIDS. 

Anatomy — Blepharitis-acuta  —  Erysipelas  —  Hordeolum — Chalazion — Ble- 
pharo-adenitis — Trichiasis  —  Eutropium  —  Canthoplasty — Ectropinm 
— Tarsoraphy — Blepharoplasty — -Ptosis^Paralysis  of  the  Orbicularis 
— Blepharospasm — Anchyloblepharon — Tumors,  -  -  167-196 

CHAPTER  X. 
DISEASES  OF   THE   CONJUNCTIVA. 

Anatomy — Hyperaemia — Conjunctivitis — Conjunctivitis  Catarrhalis — Ver- 
nal or  Autumnal  Conjunctivitis — Atropine  Conjunctivitis — Conjunc- 


CONTENTS.  IX 

PAOB. 

tivitis  Purulenta — Ophthalmia  Meonatorum — Gonorrhceal  Ophthalmia 
— Croupous  or  Membranous  Conjunctivitis — Conjunctivitis  Diphthe- 
ritica— Conjunctivitis  Trachomatosa — Trachoma — Follicular  Conjunc- 
tivitis— Conjunctivitis  Phlyctenularis — Pterygium —  Symblepharon — 
Tumors,  -.-...  .  196-235 

CHAPTER   XL 
DISEASES  OF  THE  CORNEA 

Anatomy — Keratitis  Phlyctenularis — Keratitis  Ulcerosa — Corneal  Ulcers — 
Keratitis  Diffusa:  Non-vascular;  Vascular — Keratitis  Suppurativa — 
Corneal  Opacities  —  Staphyloma  Corneas — Kerato-cornus  —  Kerato- 
globus— Tumors,  -  .....  235-262 

CHAPTER  XIL 
DISEASES  OF  THE  SCLERA. 

Anatomy  —  Scleritis  —  Episcleritis  —  Sclerotico-Choroiditis    Anterior  — 

Sclerotico-Choroiditis  Posterior,  ....  262-268 

CHAPTER    XIIL 
DISEASES   OF  THE  IRIS. 

Anatomy — Iritis — Iritis  Serosa  —  Iritis  Plastica  —  Iritis  Suppurativa  — 
Tumors — Congenital  Malformations — Functional  Diseases — Mydriasis 
— Myosis — Operations,  .  .  .  .  .  268-291 

CHAPTER  XIV. 
DISEASES  OF  THE   CILIARY  BODY. 

Anatomy —  Cyclitis— Irido-cyclitis  — Traumatic-cy clitis  —  Functional  dis- 
eases of  the  Ciliary  Muscle — Paralysis  of  the  Accommodation — Spasm 
of  the  Accommodation,  -  -     .       -  -  -  291-301 

CHAPTER  XV. 
SYMPATHETIC   OPHTHALMIA. 

Sympathetic  Irritation  —  Sympathetic  Inflammation  —  Eneucleation  — 
Optico-ciliary  Neurectomy  and  Neurotomy  —  Use  of  Artificial 
Eyes,  -  -  .....  301-311 


X  CONTENTS. 

CHAPTER  XVI. 
DISEASES  OF  THE  LENS. 

FAOZ. 

Anatomy — Cataract — Lenticular  Cataract — Soft  Cataract — Zonular  Cata- 
ract— Cortical  or  Mixed  Cataract — Hard  or  Senile  Cataract — Opera- 
tions for  Senile  Cataract;  Modified  Linear  Extraction — Capsular 
Cataract — Aphakia — Luxatio  Lentis,  ...  311-341 

CHAPTER  XVII 
DISEASES  OF  THE  VITREOUS. 

Anatomy — ^Hyalitis — Opacities  —  He  morrhage  —  Cysticercus  —  Persistent 

Hyaloid  Artery,      .......      341-347 

CHAPTER  XVIII 
DISEASES  OF  THE  CHOROID. 

Anatomy — Hyperaemia — Anaemia — Choroiditis:  Serosa;  Plastica;  Dissemi- 
nata—  Areolaris:  Suppurative  —  Sclerotico-Choroiditis  Posterior — 
Sarcoma — Detachment — Coloboma — Albinism,  -  -  347-359 

CHAPTER    XIX. 
GLAUCOMA. 

Glaucoma  —  Varieties  —  Acute  or  Inflammatory  —  Causes  —  Symptoms — 
Diagnosis  —  Treatment  —  Chronic  Causes  —  Results  of  Pressure  — 
Symptoms  —  Diagnosis  .  .  ,  .  -  359-372 

CHAPTER    XX 
DISEASES  OF   THE   RETINA. 

Anatomy  —  Hyperaemia  —  Anaemia  —  Retinitis  —  Retinitis :  Albuminurica : 
Syphilitica;  Pigmentosa:  Proliferans  —  Leucaemica  —  Detachment  of 
Retina — Functional  Diseases:  Hyperaesthesia:  Snow-Blindness:  Nyc- 
talopia: Anaesthesia:  Hemeralopia:  Commotio  Retinae:  Hemiopia: 
Scotoma— Color-Blindness— Tumors,        .  -  .  -      372-393 


CONTENTS.  H 

CHAPTER  XXL 
DISEASES  OF  THE  OPTIC  NERVE. 

PAGE. 

Anatomy — Diseases  of  the  Optio  Nerve — Hypersemia — Neuritis  Optica: 
Wooly  Disc:  Choked  Disc:  Neuritis  Descendens — Retro-bulbar  Neuritis 
— Optic  Nerve  Atrophy — Amaurosis  and  Amblyopia — Simulated  Blind- 
ness— Tnmors  of  the  Optio  Nerve,  ...  393-405 


ILLUSTRATIONS. 


KGUEE.  PAGE. 

1.  Diagram  of  a  horizontal  section  of  the  right  eye,          -            -  3 

2.  Microscopical  section  of  the  Cornea,              ....  5 

3.  Microscopical  section  of  the  Sclera,  Choroid  and  Retina,           -  6 

4.  The  Ciliary  Nerves  after  removal  of  the  Sclera,        -            -            -  9 

5.  Diagramatic  section  of  the  eyeball  showing  the  Blood-Snpply,  10 

6.  The  distribution  of  the  Retinal  Vessels,                ...  n 

7.  The  Venae  Vorticosse  and  blood  supply  of  the  Iris  and  Ciliary  body,  12 

8.  The  whorls  of  the  Venae  Vorticosae,                -            -            -             -  12 

9.  The  formation  of  the  image  upon  the  Retina,     ...  14 

10.  Diagram  of  the  changes  in  the  eye  during  Accommodation,             -  15 

11.  Diagram  of  the  Field  of  Vision  for  Colors,          .            .            .  26 

12.  Diagram  illustrating  the  theory  of  the  Ophthalmoscope,      -  29 

13.  Helmholtz's  Ophthalmoscope,        -            -            -             .            .  30 

14.  Liebreich's  Ophthalmoscope,               -            -            -            -            -  31 

15.  Loring's  Ophthalmoscope,              .....  32 

16.  Knapp's  Ophthalmoscope,      ------  33 

17.  Diagram  illustrating  the  use  of  the  Ophthalmoscope  in  the  indirect 

method,              .......  36 

18.  Ophthalmoscopic  appearance  of  the  Optic  Disc,       -            -            -  37 

19.  Liebold's  Subpalpebral  Syringe,                ....  45 

20.  Atropine  dropper,        -  -  -  -  --  -46 

21.  Desmarre's  lid-retractors,               .....  47 

22.  Noyes'  eye-speculum,                ......  48 

23.  Liebold's  eye-speculum,                   .....  48 

24.  Fixation  forceps,  .......48 

25.  Beer's  Cataract-knife,         ......  49 

26.  Sharp  gouge,  ....--.54 

27.  Spud,            -            - 64 

28.  Detachment  of  the  Iris,            ......  58 

29.  Knapp's  foreign-body  hook,           .....  62 

30.  Gruening's  magnet,      -            -            -             :            -                         -  63 

31.  Diagram  of    the   refraction   of   parallel   rays  of  light   on   passing 

through  a  convex  lens,              .....  64 

xiU 


XIV  ILLUSTRATIONS. 

FIOTJBE.  PAGE. 

32.  Diagram  illustrating  the  law  of  conjugate  foci,         -            -            -  65 

33.  Diagram  illustrating  the  refraction  of  parallel  rays  of  light  on  pass- 

ing through  a  concave  lens,     -----  Go 

34.  Diagram  showing  the  relation  of  the  visual  and  optic  axes,  the  angle 

alpha,  and  the  nodal  point  of  the  lens  system  of  the  eye,           -  65 

35.  Diagram  showing  the  relative  length  of  the  hypermetropic,  emmetro- 

pic and  myopic  eye,     ----..  67 

36.  Sections  of  spherical  glasses,              -            -            -            -            -  70 

37.  Diagram  illustrating  the  action  of  the  accommodation  upon  divergent 

rays  of  light  which  enter  the  eye,         -            -            .            -  71 

38.  Diagram  illustrating  the  correction  of  hypermetropia  by  the  use  of  a 

convex  glass,          .......  si 

39.  Section  of  a  myopic  eye,                 ....            -  86 

40.  Ophthalmoscopic  appearance  of  the  choroidal  crescent  in  myopia,  87 

41.  Circular  atrophy  of  the  choroid  around  the  disc  in  myopia,         -  87 

42.  The  correction  of  myopic  refraction  by  the  use  of  a  concave  glass,  -  91 

43.  Test-card  for  determining  astigmatism,                -            -            -  97 

44.  Muscles  of  the  eyeball,            -            -            .            -            .  102 

45.  Diagram  illustrating  the  production  of  direct  diplopia,            -  105 

46.  Diagram  illustrating  the  production  of  crossed  diplopia,      -            -  106 

47.  Dot-and-line  for  determining  insufficiency  of  the  recti  muscles,  115 

48.  The  Strabismometer,                 ..-.--  120 

49.  Curved  strabismus  scissors,            -            -            -            -            -  123 

50.  Strabismus  forceps,  -  -  -  -  -  -123 

61.  Strabismus  hook,                  ......  i23 

52.  Operation  for  Strabismus  Convergens,          ....  i24 

53.  Needle  forceps,        -            -            -            -            -            -            -  125 

64.  The  bony  orbit,            -------  131 

55.  Diagram  of  the  canaliculi  and  lachrymal  sac,      ...  151 

56.  Dissection  showing  the  opening  of  the  nasal  duct  beneath  the  inferior 

turbinated  bone,            ......  151 

67.  Anel's  canaliculus  probes,        ......  154 

68.  Weber's  canaliculus  knife,              .....  155 

69.  Passage  of  the  lachrymal  probe,          .....  157 

60.  Stilling's  knife  for  lachrymal  strictures,   ....  158 

61.  Bowman's  lachrymal  probes,                .....  159 

62.  Weber's  conical  lachrymal  probe,               .            -            -            -  159 

63.  Williams'  bulbous  pointed  probes,       -            -            -            -            .  159 

64.  Mucocele,     ..--.--.  164 
66.  Diagramatic  section  of  the  upper  lid,              ....  iqq 

66.  Clamp  forceps  for  lid  operations,               -            -            -            -  173 

67.  Knapp's  entropium  forceps,    -  -  -  -  -  -174 

68.  Cilia  forceps,            -------  181 

69.  Horn  spatula  for  lid  operations,          ....            -  182 

70.  Operation  of  transplantation  of  the  cilia,              -            -            -  182 
71    and  72.     Entropium,                 -            -            -            -            -            -  183 

73   and  74.    Hotz's  operation  for  entropium,             .           ,            .  j^r. 


ILLUSTRATIONS.  XV 

FIGTIBE.  PAGE. 

75.  Canthoplasty,                 .......  igQ. 

76.  Ectropium,                .......  isft 

77    and  78.    Wharton  Jones'  operation  for  ectropium,                -            .  187 

79    and  80.     Adam's  operation  for  ectropium,            -            -            -  187 

81    and  82.     Diffenbach's  operation  for  ectropium,         ...  188 
83    and  84.     Operation  of  Tarsoraphy,             -             -             -             -      188-189 

85.  Arlt's  blepharoplasty  operation,           .....  i89 

86.  JKnapp's  operation  for  Blepharoplasty,      ....  190 

87.  Granulations  of  the  conjunctiva — granular  lids,         ...  22G 
88-89-90.  Teale's  operation  for  symblepharon,            ...  233 

91.  Microscopical  section  of  the  cornea,                ....  236 

92.  Desmarre's  paracentesis  knife,       ....            -  246 

93.  Broad  eye-needle,          .--.-..  246. 

94.  Weber's  beak-pointed  canaliculus  knife,  .              ...  246 
95    and  96.     The  notched  teeth  of  Hutchinson,    -            -            -            .  250 

97.  Tattooing-needles,               ------  258 

98.  Conical  cornea,             .......  260 

99.  The  muscular  fibres  of  the  Iris,      .....  269 

100.  Straight  keratome,        .......  286 

101.  Angular  keratome,               ......  286 

102.  Linear  cataract-knife,                ......  286 

103.  Angular  Iris-forceps,            --....  286 

104.  Straight  Iris-scissors,                ......  287 

105.  Curved  Iris-scissors,             ......  287 

106.  Iridectomy — incision  of  the  Cornea,                -            -            -            .  288 

107.  Iridectomy — cutting  of  the  Iris,                  ....  288 

108.  Iridectomy — appearance  of  the  coloboma  when  the  section  is  made 

outward,      -----...  289 

109.  Iridectomy — appearance  of  the  coloboma  when  the  section  is  made 

upward,               .......  289 

110.  Liebold's  Iris-scissors,               ......  289 

111.  Artificial  eye,            .......  308 

112.  Soft  cataract  under  focal  illumination,            ....  3^5 

113.  Soft  cataract  with  irregularities  in  its  substance,              -            -  315 

114.  Operation  of  Discission,            ......  317 

115.  Operation  for  Linear  Extraction,                 ....  313 

116.  Removal  of  the  lens-matter  through  the  incision,                  -            -  319 

117.  Section  of  a  Zonular  Cataract  showing  its  lamellar  opacity,        -  319 

118.  The  appearance  of  Zonular  Cataract  under  focal  illumination,         -  320 

119.  The  same  when  viewed  by  the  transmitted  light  of  the  ophthalmo- 

scope,                 .......  321 

120.  Section  of  a  Cortical  Cataract,            -            -            .            .            .  321 

121.  The  appearance  of  Cortical  Cataract  when  viwed  by  the  ophthalmo- 

scope,                  .......  321 

122.  The  same  when  examined  by  focal  illumination,        -            -            -  321 

123.  Section  of  a  Hard  or  Nuclear  Cataract,                   ...  322 

124.  The  appearance  of  Hard  Cataract  when  viewed  by  focal  illumination,  323 


XVI  ILLUSTRATIONS. 

FIGUBE,  PAGE. 

125.  Hard  Cataract  when  examined  with  the  ophthalmoscope,            -  323 

126.  Incision  in  Flap  operation  for  Cataract,        ....  330 

127.  Incision  in  Graefe's  Modified  Linear  operation,                -            •  830 

128.  LeBrun's  and  Liebrich's  Incisions,                   ....  330 

129.  Von  Graefe's  Operation  for  Cataract,        -            -            .            .  331 

130.  Fixation  Forceps,          --•.-..  333 

131.  Linear  cataract  knife,          .-.-..  334 

132.  Hard  mbber,  or  silver,  Lens  scoop,                  ....  334 

133.  Angular  Iris-forceps,           ----..  334 

134.  Curved  Iris-scissors,                  ......  335 

135.  Cystotome,                .......  335 

136.  Fenestrated  Wire  Lens  Scoop,              -            .            .            -            .  336 

137.  Line  of  the  various  incisions  of  the  cornea  for  Cataract  Extrac- 

tion,       -.--.-..  837 

138.  Posterior  Polar  Cataract,         -.-.-.  838 

139.  Pigment  and  Stroma  cells  of  Choroid,       -            .            -            .  348 

140.  Section  of  Eye  showing  whorls  of  Venae  Vorticosae,                -            -  348 

141.  Ophthalmoscopic  appearance   of   fundus  in  Choroiditis   Dissem- 

inata,                  .......  353 

142.  Section  of  Optic  Nerve  showing  the  Glaucomatous  cupping,             -  864 

143.  Ophthalmoscopic  appearance  of  Glaucomatous  Cop,                    -  865 

144.  Line  of  sections  of  the  Cornea  in  Iridectomy  and  Sclerotomy,            -  870 

145.  Injection  of  the  capillary  Vessels  of  the  Macula  Lutea,                -  873 

146.  Diagramatic  Section  of  the  Retina,                  ....  873 

147.  Hexagonal  pigment  cells  of  the  Retina,                 ...  874 

148.  Section  of  the  Eye,  showing  Detachment  of  the  Retina,        -            -  884 

149.  Ophthalmoscopic  appearances  of  Detachment  of  the  Retina,       -  385 

150.  Section  of  the  Optic  Nerve  and  the  appearance  of  the  Optic 

Disc,            -            -            .            -            -            .            -            -  894 


BIBLIOGRAPHY. 


Graefe  and  Saemisch:  Handbnch  der  gesammten  Augenheilkunde. 

Stellwag:  Treatise  on  Diseases  of  the  Eye. 

Soelberg  T.ells :  Treatise  on  Diseases  of  the  Eye. 

Schweigger:  Handbuch  der  Augenheilkunde. 

Carter:  On  the  Eye, 

Macnamara:  Diseases  of  the  Eye. 

Nettleship :  Diseases  of  the  Eye. 

Donders:  Accommodation  and  Refraction. 

Alt:  The  Human  Eye. 

Mittendorf :  Diseases  of  the  Eye  and  Ear. 

Gowers:  Medical  Ophthalmoscopy. 

DeWecker :  Ocular  Therapeutics. 

Albutt:  The  Ophthalmoscope. 

Galezowski:  Traite  des  Maladies  des  Yeui. 

Landolt:  Examination  of  the  Eyes. 

Noyes:  Diseases  of  the  Eye. 

Knapp :  Archives  of  Ophthalmology. 

Royal  London  Ophthalmic  Hospital  Reports. 

Norton:  Ophthalmic  Therapeutics. 

Many  smaller  works,  Monographs  and  Journals. 


ISEASES  AND  INJURIES  OF  THE  EYE. 


CHAPTER   I. 


GENEEAL  ANATOMY  AND  PHYSIOLOGY. 


To  comprehend  the  various  changes  which  result  from 
disease  or  injury  to  the  eye,  a  full  knowledge  of  the  anatomy 
and  physiology  of  this  organ  becomes  necessary.  Without  it, 
a  proper  appreciation  of  the  value  of  the  pathological  changes 
which  may  result,  in  either  a  medical  or  surgical  sense,  is 
impossible.  Hence,  a  review  of  the  general  anatomy  of  the 
eye,  at  this  time,  will  be  followed  by  a  more  detailed  descrip- 
tion of  the  histology  of  the  separate  portions  in  the  various 
chapters,  according  to  their  importance. 

ANATOMY. 

The  human  organ  of  vision  consists  essentially  of  a  hollow 
sphere  into  which  the  light  vibrations  are  conducted  through 
its  anterior  transparent  portion  and  its  refractive  media,  to  fall 
upon  the  percipient  elements  in  the  expansion  of  the  optic 
nerve  upon  the  interior.  For  visual  perception  the  eyeball 
with  its  contents  alone  is  necessary;  but  connected  with  it  are 
muscles,  nerves,  blood-vessels,  and  other  parts  especially 
designed  for  its  nutrition  and  protection.  The  eyeball  is 
suspended  in  the  pyramidal  ca\dty  of  the  orbit  at  an  equal 


^  DISEASES  AND  INJURIES  OF  THE  EYE. 

distance  from  its  walls,  and  rests  upon  a  cushion  of  loose  fat 
and  connective  tissue,  from  which  it  is  separated  by  a  fibrous 
expansion — the  capsule  of  Tenon.  It  is  freely  movable  in 
every  direction  about  its  center  of  rotation  in  this  mem- 
branous   socket   by  the  muscles  inserted  into  its  outer  coat. 

Through  its  capsule,  its  vascular  and  lymph  supply,  and 
the  optic  nerve,  it  is  in  direct  communication  with  the  brain 
and  its  membranes.  It  is  thoroughly  protected  from  external 
injury  by  the  strong,  bony  margin  of  the  orbit,  the  eyelids 
and  their  cilia  and  the  delicate  mucous  membrane  covering  it 
externally.  This  membrane  is  also  reflected  upon  the  eyelids, 
forming  a  soft  and  moist  membrane,  necessary  to  preserve  the 
transparency  of  the  anterior  part  of  the  globe.  This  mem- 
brane, the  conjunctiva,  is  continuous  through  the  lachrymal 
canals  with  that  of  the  nasal  cavities,  and  with  the  integument 
of  the  face  at  the  margin  of  the  eyelids.  Its  moisture  is 
derived  from  the  secretions  of  its  own  glands  and  also  from 
the  lachrymal  gland  which  is  lodged  in  the  upper  and  outer 
angle  of  the  orbit,  and  sends  numerous  ducts  to  open  upon 
the  internal  surface  of  the  outer  part  of  the  upper  lid.  The 
conjoined  secretions,  after  passing  over  the  conjunctiva,  are 
received  by  the  two  jnmcia  lachrymalia  at  the  inner  canthus, 
.or  angle  of  the  lid,  which  open  into  minute  horizontal  canals, 
the  canalicuU.  These  carry  the  tears  to  the  lachrymal  sac, 
from  which  they  pass  directly  to  the  nose  through  the  lach- 
■rymal  and  nasal  ducts. 

The  eyeball,  while  presenting  a  globular  or  spherical  form, 
is  really  formed  by  the  union  of  portions  of  two  hollow  spheres 
of  different  diameter,  of  which  the  anterior  and  more  promi- 
nent segment  is  the  smaller ;  the  segment  of  the  larger  opaque 
surface  corresponds  with  the  limit  of  the  sclerotic  portion,  and 
the  translucent  portion  of  the  smaller  sphere  with  that  of  the 
cornea.  The  antero-iiosterior  diameter,  or  axis  of  the  eyeball 
is  a  line  drawn  perpendicularly  through  the  centre  of  the 
cornea  to  the  sclerotic,  and  measures  about  .95  of  an  inch,  or 
24.3  mm.  in  length.  Its  transverse  diameter  is  a  horizontal 
line  drawn  perpendicular  to  its  axis  at  the  centre  of  the  eyeball 


ANATOMY. 


and  measures  .93  of  an  inch,  or  23.6  mm.  The  vertical  diam- 
eter is  a  line  drawn  at  right  angles  to  both  these  lines  at  the 
centre,  and  gives  a  length  of  .92  of  an  inch,  or  23.4  mm. 
The  anterior  pole  of  the  eye  is  the  geometric  centre  of  the 

^       Dip 

a 


cornea,  the  postei'ioi'  pole  being  the  centre  of  the  back  part  of 
the  globe.  The  ojiiic  axis  is  the  line  connecting  these  two 
points.  The  visual  axis  is  an  imaginary  line  drawn  from  the 
object  looked  at  to  the  macula  lutea,  the  visual  centre  of  the 
retina,  and  cuts  the  cornea  slightly  above  and  to  the  inner  side 


4  DISEASES  AND  INJURIES  OF  THE  EYE. 

of  the  optic  axis.  The  equator  is  the  circle  passing  around 
the  eye  midway  between  the  two  poles.  The  meridians  of  the 
eye  are  circles  formed  by  planes  passing  through  the  centre  of 
the  eyeball,  the  two  principal  meridians  being  the  horizontal 
and  the  vertical. 

The  eyeball  is  composed  of  several  investing  tunics,  enclos- 
ing fluid  and  solid  contents,  called  the  refracting  media.  The 
tunics,  or  investing  membranes,  are  three  in  number,  \vz:  an 
external  fibrous  membrane  forming  the  Cornea  (C  Fig.  1) 
and  Sclera  (>S)  ;  a  middle  vascular  and  partly  muscular  mem- 
brane, the  Choroid  {Ch)  Ciliary  body  {^Pc)  and  Iris  (J),  and 
an  internal  nervous  stroma,  the  Retina  (i2).  The  enclosed 
refracting  media  are  the  Aqueous  humor  {Ac),  the  Lens  (i), 
and  Vitreous  {^VB),  the  most  important  being  the  crystalline 
lens,  which  is  a  double  convex  body  enclosed  in  a  transparent 
capsule  and  situated  immediately  behind  the  pupil.  It  is. 
retained  in  position  by  a  suspensory  ligament,  the  zonule  of 
Zinn  {ZZ),  which  connects  its  periphery  with  the  anterior 
margin  of  the  retina  and  the  ciliary  processes.  The  space 
between  the  anterior  portion  of  the  lens  and  the  posterior 
surface  of  the  cornea  is  filled  with  the  aqueous  humor  and  is 
divided  by  a  movable  partition,  the  iris,  into  the  anterior  [Ac) 
and  posterior  {Pc)  chambers.  The  Vitreous  ( VB)  which 
occupies  about  four-filths  of  the  eyeball  posteriorly,  fills  the 
cavity  behind  the  lens  and  consists  of  an  albuminous  fluid 
inclosed  in  a  delicate  membrane,  the  hyaloidea. 

The  Sclerotic  [S  Fig.  1),  having  a  thickness  of  nearly  1-25 
of  an  inch  or  from  .7  to  .9  mm.  is  a  strong,  opaque,  unyielding, 
fibrous  structure  which  maintains  the  form  of  the  eye  and 
gives  support  to  the  delicate  interior  structures,  and  allows  of 
the  entrance  and  exit  of  nerves  and  blood-vessels  which  supply 
the  parts  within.  It  extends  over  about  five-sixths  of  the 
eyeball,  joining  in  front  with  the  comea*  The  outer  surface 
is  white  and  smooth  except  where  the  tendons  of  the  recti  and 
oblique  muscles  are  inserted  into  it.  About  1-10  of  an  inch 
to  the  inner  or  nasal  side  of  the  posterior  pole  of  the  globe,  is 
an  opening,   partially  closed  by  a  sieve-like  membrane,  the 


ANATOMY. 


5 


lamina  cribrosa  {Lc),  1-13  of  an  inch,  or  2  mm.  in  diameter, 
for  the  entrance  of  the  fibres  of  the  optic  nerve  [ON).  The 
sclera  is  thickest  behind ;  thinnest  about  1-4  of  an  incli  or  6 
mm.  from  the  cornea  and  thicker  again  at  its  junction  with  the 
latter.  Its  blood  supply  is  very  slight,  and  derived  from  the 
•ciliary  vessels.     It  is  largely  deficient  in  nerves. 

The  Cornea  (C)  forms  the  anterior  one-sixth  of  the  external 
coat,  and  presents  a  thickness  of  about  1-28  of  an  inch,  or  .9 
mm.  at  its  apex,  and  1-22  of  an  inch,  or  1.2  mm.  at  its  margin. 

It  is  a  perfectly  transparent, 
highly  polished  membrane, 
and  having  a  shorter  radius 
projects  from  the  sclera,  and 
admits  the  light  to  the  inte- 
rior of  the  eye.  It  presents 
an  ellipsoidal  shape,  having 
its  horizontal  diameter  rather 
longer  than  the  vertical,  ow- 
ing to  the  overlapping  of  the 
sclera,  of  which  it  is  a  mod- 
ified continuation.  It  con- 
sists of  five  layers  (Fig.  2) ; 
an  outer  layer  of  epithelium 
(1)  continuous  with  the  con- 
junctiva, a  thin  structureless 
membrane  (2),  a  thicker 
central  layer  or  true  corneal 
tissue  (3),  a  posterior  elastic 
membrane  (1),  and  upon  the 
latter  a  layer  of  endothelium  (5).  The  cornea  has  no  blood- 
vessels except  at  its  margin,  and  is  nourished  by  endosmosis 
from  these  capillary  vessels.  Its  nerve  supply  is  very  abun- 
dant and  is  derived  from  the  ciliary  nerves. 

The  Canal  of  Schlemm  [Sc  Fig.  1)  is  a  circular  venous 
sinus  which  surrounds  the  anterior  portion  of  the  eye.  It  is 
situated  in  the  sclerotic,  close  to  its  junction  with  the  cornea. 
A  minute  open  space  has  been  traced  from  it  into  the  anterior 


FIG.  2. 


6  DISEASES  AND  INJURIES  OF  TEE  EYE. 

chamber  {AC)  from  which,  it  is  separated  by  the  ligamentum. 
pectinatum.  It  forms  the  exit  from  the  anterior  chamber  of 
the  aqueous  fluid  which  is  derived  from  the  vessels  of  the  iris 
and  ciliary  processes.  Upon  the  patency  of  this  canal  depends, 
the  condition  of  the  intra-ocular  tension. 

The  Choroid  [Ch  Figs.  1  and  3)  is  a  dark,  brown  membrane 
1-300  to  1-150  of   an  inch  in  thickness,  lying   between   the 
scler-a  and  the  retina.     It  consists  almost  entirely  of   blood- 
vessels united  by  a  delicate  connective  tissue,  and  forms  the 
nutrient  membrane  for  the  lens    and 
vitreous.     It  is  loosely  attached  to  the 
sclera,  except  where  the  optic  nerve  i& 
transmitted,  and  reaches  forward  nearly 
to  the  cornea,  where  it  ends  in  a  series 
of  folds  or  plaits,  seventy  in  number, 
called  the  ciliary  processes,   where  it 
again   becomes   more   firmly   attached 
to   the    sclera.     In   the   choroid,    four 
layers  are  described.     Externally  and 
resting  upon  the  inner  surface  of  the 
sclera,  is  a  loose  connective  tissue  con- 
taining  branching    black    and    brown, 
pigment  cells  surrounding  the  vessels. 
^^•^-  and  nerves   which   pass    from   behind 

forward  to  supply  the  iris  and  ciliary  body.  Owing  to  its 
loose  attachment  to  the  sclera,  a  minute  space  (Pc/i  Fig.  3) 
is  left  which  is  lined  by  endothelium  and  forms  a  lymph  space, 
which  connects  with  Tenon's  space  about  the  exit  of  the  veins 
of  the  choroid  where  they  pierce  the  sclera.  The  second  layer 
consists  of  larger  branches  of  the  ciliary  arteries  and  whorl- 
like veins,  the  venae  vorticossB  [VV  Fig.  1),  which,  passing 
deeper  and  becoming  smaller,  form  the  third  layer,  or  layer 
of  capillary  vessels.  The  fourth  layer  consists  of  a  minute 
structureless  limiting  membrane  Avhicli  gives  the  smooth 
inner  surface  to  the  choroid,  and  is  covered  by  the  hexagonal 
pigment  cells  of  the  retina. 

The  Ciliary  processes  [Pc  Fig.  1),  about  seventy  in  number. 


ANATOMY.  i 

are  formed  by  the  folding  of  that  portion  of  the  choroid  which 
lies  anterior  to  the  equator  of  the  globe,  the  pigment  layer  of 
the  retina  being  continued  forward  as  a  covering.  These 
processes  are  arranged  radially  together  in  the  form  of  a 
circle.  They  consist  of  larger  and  smaller  folds,  without 
regular  alternations,  the  small  folds  being  in  number  about 
one  third  that  of  the  larger.  Into  these  folds  of  the  ciliary 
processes,  fit  corresponding  plications  of  the  suspensory  liga- 
ment of  the  lens. 

The  Ciliary  muscle,  the  muscle  of  accommodation,  is  a 
circular  band  of  involuntary  muscular  fibres  which  take  both 
a  circular  and  meridional  course.  This  muscle  underlies  the 
ciliary  processes  and  they  together  form  the  Ciliary  body.  The 
fibres  of  the  ciliary  muscle  arise  from  a  tendinous  ring  at  the 
inner  side  of  the  canal  of  Schlemm.  The  meridional  fibres 
pass  backward  and  are  lost  in  the  tissue  of  the  choroid,  while 
the  circular  fibres  form  a  sphincter  or  ring  muscle.  The 
ciliary  body  is  largely  supplied  with  vessels  and  nerves. 

The  Iris  (J  Fig.  1)  is  the  contractile  and  colored  membrane, 
which  is  seen  behind  the  transparent  cornea  and  gives  the  tint 
to  the  eye.  It  is  a  movable  muscular  curtain,  with  a  central 
perforation,  the  pupil,  which  regulates  the  amount  of  light 
admitted  to  the  eye.  The  iris  measures  about  one-half  an 
inch  across,  and  in  a  state  of  rest  about  one-fifth  of  an  inch 
from  the  circumference  to  the  pupil.  The  iris  consists  of  a 
loose  stroma  of  connective  tissue,  containing  muscular  fibres, 
blood  vessels,  nerves  and  pigment  cells,  and  may  be  regarded 
as  a  process  of  the  choroid,  with  which  it  is  continuous.  The 
pigment  layer  of  the  retina  is  continued  forward  upon  the 
posterior  surface  of  the  iris.  Immediately  beneath  this  are 
muscular  fibres  of  the  iris  which  take  a  radial  course  at  the 
periphery,  the  dilator  of  the  pupil,  while  at  the  pupillary 
margin  are  seen  the  circular  fibres  of  the  sphincter  muscle  of 
the  pupil.  The  blood  supply  is  derived  from  the  ciliary  body, 
the  nerves  coming  from  the  third,  fifth,  and  sympathetic. 
The  anterior  surface  is  variously  colored  in  different  eyes,  and 
is  marked  by  waved  lines  converging  towards  the  pupil,  while 


8  DISEASES  AND  INJURIES  OF  THE  EYE. 

at  the  pupillary  margin,  the  surface  is  drawn  into  minute 
concentric  folds.  The  anterior  surface  is  covered  by  irregular 
endothelial  cells  continuous  with  those  of  the  posterior  layer 
of  the  cornea. 

The  Retina  (-B  Figs.  1  and  3)  is  the  delicate  transparent 
expansion  of  the  optic  nerve,  extending  as  far  forward  as  the 
ciliary  processes,  where  it  terminates  by  an  irregular  margin, 
the  Ora  Serrata  {OS).  From  this  border  a  thin  layer  of 
laminated  cells  is  continued  with  the  pigment  layer  forward 
on  to  the  ciliary  processes,  and  forms  the  ciliary  portion  of  the 
retina.  It  lies  within  the  choroid  and  rests  upon  the  hyaloid 
membrane  of  the  vitreous.  The  thickness  of  the  retina 
diminishes  from  behind  forwards,  varying  from  1-50  to  1-200 
of  an  inch.  It  is  made  up  of  some  ten  layers,  four  of  which 
may  be  considered  of  importance.  The  most  external  layer  is 
that  of  the  hexagonal  pigment  cells  upon  the  surface  of  the 
choroid;  arranged  vertically  upon  this  is  a  layer  of  rods  and 
cones  which  cover  the  expansion  of  the  retina,  being  more 
closely  aggregated  at  the  macula  lufca  which  has  in  its  centre  a 
depression  or  the  fovea  centralis  [Fc  Fig.  1 )  where  only  cones 
are  found.  The  rod  and  cone  layer  presents  a  delicate  coloring 
matter,  the  retinal  purple,  which  is  formed  by  the  pigment 
layer.  The  internal  layer  of  the  retina  consists  of  the  expan- 
sion of  radial  fibres  of  the  optic  nerve,  the  larger  portion 
of  the  fibres  sweeping  towards  the  temporal  side  about  the 
macula  lutea.  Between  these  external  and  internal  layers  are 
the  remaining  layers,  consisting  of  ganglionic  cells,  granules 
and  fibres  which  connect  the  percipient  elements  with  the 
conducting  filaments.  The  blood  supply  of  the  retina  is 
mainly  from  the  central  artery  of  the  nerve,  the  most  external 
layers  being  nourished  by  osmosis  from  the  choroid. 

The  Optic  nerve  [ON  Fig.  1)  arises  in  the  brain  from  two 
roots  having  their  origin  in  the  gray  matter  of  the  occipital 
lobes,  intimately  connected  with  the  corpora  geniculata,  optici 
thalami  and  corpora  quadrigemina,  which  receive  fibres  from 
other  portions  of  the  brain  and  spinal  cord,  and  run  forward 
as  the  optic  tracts  until  they  unite  to  form  the  optic  chiasma, 


ANATOMY.  9 

in  which  they  decussate  and  turn  off  to  either  side,  each  tract 
sending  fibres  to  supply  the  inner  half  of  the  opposite  eye, 
the  greater  portion,  however,  passing  directly  to  the  outer  half 
of  the  retina  of  the  same  side.  Some  fibres  have  also  been 
traced  as  passing  from  one  eye  to  the  other.  The  optic  nerves 
proper  as  they  emerge  from  the  optic  foramina  are  covered 

by  a  delicate  neurilemma  which 
is  continuous  with  the  pia  mater 
and  forms  the  pial  sheath.  More 
externally  is  a  dense  fibrous  sheath 
continuous  with  the  dura  mater. 
These  sheaths  are  joined  together 
■^®*  *•  by  a  loose  connective  tissue  and 

form  a  lymph  space,  the  inter-vaginal,  extending  up  to  the 
sclera,  which  is  in  direct  connection  with  the  arachnoidal  space 
of  the  brain.  The  nerve  in  the  orbit  is  about  one  and  one-eighth 
inches  long  and  passes  forward  to  enter  the  eye  through  the 
scleral  ring,  a  little  below  and  to  the  inner  or  nasal  side  of 
the  posterior  pole  of  the  ball.  It  is  made  up  of  a  large 
number  of  bundles  of  medullated  fibres,  which  as  they  pass 
through  the  perforated  opening  in  the  sclera,  leave  their 
sheaths  behind  and  radiate  from  the  disc  in  all  directions. 
The  optic  disc  or  'papilla  is  the  point  of  entrance  of  the  optic 
nerve.  The  central  artery  of  the  retina  (e  Fig.  5)  enters  the 
nerve  fifteen  to  twenty  mm.  behind  the  eyeball,  and  passing 
to  the  center  of  the  nerve  runs  forward  to  appear  upon  the 
disc  (Fig.  6),  where  it  divides,  usually,  into  two  or  more 
branches,  which  ramify  through  the  inner  layers  of  the  retina. 
The  nerves  of  the  eije  in  addition  to  the  optic,  are  the  third, 
fourth,  ophthalmic  division  of  the  fifth,  and  the  sixth.  The 
third  is  a  motor  nerve  and  supplies  the  superior,  inferior  and 
internal  recti,  inferior  oblique,  the  levator  palpebrse  and 
ciliary  muscles,  together  with  the  sphincter  of  the  iris.  It 
also  sends  a  branch  to  the  ciliary  ganglion.  The  fourth  nerve 
supplies  the  superior  oblique,  and  the  sixth  the  external 
rectus.  The  fifth  sends  sensory  branches  to  the  lids  and 
■conjunctiva,   two  to  three  long  ciliary  nerves  to  the  eyeball. 


10 


DISEASES  AND  INJURIES  OF  THE  EYE. 


and  furnishes  a  sensory  root  to  the  ciliary  ganglion.  The 
ciliary  ganglion  is  a  minute  flattened  lenticular  body  which 
lies  deep  in  the  orbit  between  the  optic  nerve  and  external 
rectus  muscle.  It  has  motor,  sensory,  and  sympathetic  roots. 
From  its  anterior  border  several  branches  are  given  off  which 
divide  into  fifteen  or  twenty,  the  short  ciliary  nerves,  and 
these  together  with  the  long  ciliary  nerves  from  the  third 
nerve,  pass  along  the  optic  nerve  sheath  and  pierce  the  sclera 
around  the  optic  nerve  entrance.     The  ciliary  nerv^es  (Fig.  4) 


pass  directly  to  the  inner  surface  of  the  sclera  and  advance  to 
the  ciliary  body  where  a  plexus  is  formed  which  supplies  the 
iris,  ciliary  muscle,  choroid,  cornea  and  blood-vessels. 

The  blood  supply  of  the  eyeball  is  divided  into  three 
systems:  First,  the  short  or  posterior  ciliary  arteries  {^aa 
Fig.  5),  which  are  derived  from  the  ophthalmic,  and  consist  of 
some  twenty  branches  which  pass  through  the  sclerotic  around 
the  optic  nerve  entrance  and  supply  the  choroid  together  with 
the  long  ciliary  arteries  (6  Fig.  5),  two  in  number,  having  the 
same  origin  as  the  others,  which  perforate  the  sclera  in  front 
of  the  short,  one  on  the  nasal  and  the  other  on  the  temporal 
side,  and  then  pass  forward  to  form  the  complex  vascular 
system  of  the  anterior  portion  of  the  choroid,  ciliary  body  and 
iris. 

Second,    the    anterior    ciliarj'    arteries    (c  Fig.    5)    which. 


ANATOMY. 


li 


arising  from  the  muscular  branches,  pass  through  the  tendons 
of  the  recti  muscles,  pierce  the  sclera  at  four  to  six  mm.  from 
the  cornea,  and  passing  forward  form  the  arterial  loops  in  the 
margin  of  the  cornea  (r),  and  supply  the  ciliary  body  (r), 
the  iris  (g)  and  anterior  parts  of  the  sclera  [n).  They 
become  visible  to  the  naked  eye  only  in  inflammation  of 
these  parts. 

Third,  the  central  artery  of  the  retina   (e  Fig.  5,  Fig.  6), 
which  enters  the  optic  nerve  about  15  to  20  mm.  behind  the 
eyeball,   and  passing  to  its  centre  emerges  upon   the   optic 
_  papilla  and  there  divides  into 

two  branches,  one  above  and  one 
below.  These  again  dividing 
and  arching  out,  supply  the 
inner  layers  of  the  retina,  leav- 
1  ing  the  portion  occupied  by  the 
j  macula  lutea  comparatively  free. 
(  See  Fig.  6 ) .  The  veins  of  the 
cornea,  iris  and  ciliary  body 
follow  closely  the  arrangement 
of  the  arteries,  but  in  the 
choroid  after  numerous  ramifi- 
cations and  anastomoses  they 
unite  into  large  whorls,  the  vense  vorticosse  [v  Fig.  7  and  1 
Fig.  8),  which  are  four  to  six  in  number  and  have  large  trunks, 
which  pass  out  through  the  sclera  near  the  equator,  and  carry 
ofi"  the  major  portion  of  the  blood  from  the  uveal  tract.  There 
are  no  ^eins  corresponding  to  the  long  ciliary  arteries.  The 
venous  blood  from  the  eye  is  emptied  through  the  superior 
and  inferior  ophthalmic  vein  into  the  cavernous  sinus. 

The  hjmpliatic  system  of  the  eyeball  is  necessarily  complex 
and  extensive,  from  the  fact  that  were  blood-vessels  used  to 
carry  the  product  they  would  interfere  with  distinct  vision  by 
lessening  the  transparency  of  the  various  tissues.  Hence,  the 
circulation  of  the  nutrient  fluid,  in  the  form  of  colorless  lymph, 
is  carried  on  through  these  channels.  Upon  the  interruption 
or  rapidity  of  this  flow  depends  the  tension,  or  fluid  pressure, 


FIG.  6. 


12 


DISEASES  AND  INJURIES  OF  THE  EYE. 


of  the  eyeball.  The  lymph  formed  in  the  different  tissues  of 
the  eye,  after  having  nourished  the  parts  for  which  it  is 
intended,  passes  out  through  three  different  channels,  the 
canal  of  Schlemm,  the  spaces  around  the  choroidal  veins,  and 
through  the  optic  nerve.  That  formed  in  the  anterior  portion 
of  the  eyeball  being  principally  derived  from  the  iris  and 
ciliary  body ;  that  secreted  by  the  ciliary  body,  after  supplying 
the  vitreous  and  posterior  layers  of  the  lens,  finds  its  way 
through  minute  openings  in  the  zonule  of  Zinn.  [ZZ  Fig.  1) 
into   the   posterior   chamber,  where    it  is   increased  by  that 


Fia.  & 


FIG.  7. 


coming  from  the  iris  and  thence  passes  into  the  anterior 
chamber  between  the  iris  and  lens;  the  iris  in  its  normal 
condition  being  so  applied  to  the  lens  as  to  prevent  any  reflux 
into  the  posterior  chamber,  it  mingles  with  the  secretion  from 
the  anterior  surface  of  the  iris  and,  in  part,  from  the  mem- 
brane of  Descemet  and  cornea.  This  commingled  ^uid  finds 
an  exit  through  the  meshes  of  the  ligamentum  pectinatum  at 
the  angle  of  the  iris  into  the  canal  of  Schlemm  [Sc  Fig.  1), 
where  it  meets  the  lymph  which  has  been  used  in  nourishing 
the  cornea,  and  passes  out  into  the  anterior  ciliary  veins, 
(c'  Fig.  5).  There  is  an  unexplained  resistance  upon  the  part 
of  the  lymphatics  which  retards  the  flow  sufficiently  to 
preserve  a  proper  tension  of  the  fluid  in  the  anterior  chamber. 
Tlie  lymph  formed  in  the  choroid  and  sclera  passes  into  the 
space  between  these  membranes  [Pch  Fig.  3)  which  exists  in 
the  loose  trabecular  tissue  formed  by  the  supra-choroidea  and 


PHYSIOLOGY.  IB 

lamina  fusca,  which  conDect  the  Wo  tunics,  and  which 
presents  lamellaB  covered  by  endothelial  cells;  around  the 
trunks  of  the  venae  vorticosae  (/i  Fig.  5)  as  they  pass  out 
through  the  sclera  at  the  equator  lymph  sheaths  have  been 
described  which  communicate  with  Tenon's  space,  the  lymph 
space  between  the  outer  surface  of  the  sclera  and  inner 
surface  of  the  capsule  of  Tenon,  which  extends  along  the  optic 
nerve  and  thus  gives  exit  to  the  lymph  from  the  choroid  and 
sclera  to  the  arachnoidal  cavity  of  the  brain,  through  the 
canalus  opticus.  The  third  mode  of  exit,  that  for  the  lymph 
from  the  retina  and  inner  portions  of  the  optic  nerve,  is  by 
canals  around  the  blood-vessels,  particularly  the  capillaries 
and  veins  passing  out  through  the  lamina  cribrosa. 

The  lymph  space  of  the  optic  nerve  will  be  considered  in 
the  chapter  devoted  to  the  discussion  of  its  anatomy  and 
diseases. 

PHYSIOLOGY    OF    THE    EYE. 

Eays  of  light  falling  upon  the  retina  cause  what  is  termed  a 
sensation  of  light,  but  to  obtain  distinct  vision  of  any  object 
an  image  of  that  object  must  be  formed  on  the  retina.  These 
rays  of  light  impinging  upon  the  retina,  give  rise  to  sensory 
impressions  through  some  excitation  of  the  nerv^e  terminations 
in  the  retina.  This  excitation  is  accomplished  by  the  mechan- 
ical irritation  due  to  the  vibrations  of  the  luminous  rays,  to 
changes  in  the  electric  currents  of  the  nerves,  to  chemical 
decomposition  of  certain  matters  in  the  retina,  and  to  changes 
in  the  temperature  due  to  the  rays.  These  sensory  impulses 
transmitted  along  the  optic  nerve  through  certain  portions  of 
the  brain,  and  possibly  modified  in  their  passage,  affect  our 
consciousness  and  become  sensations. 

Luminous  rays  of  light,  passing  through  a  bi-convex  lens, 
which  is  a  lens  with  two  convex  surfaces,  are  brought  together 
at  a  point  on  the  opposite  side  of  the  lens.  These  rays  if  they 
proceed  from  a  luminous  object,  as  a  candle,  diverge,  and,  fall- 
ing upon  the  bi-convex  lens,  are  again  converged  by  it  and 


14 


DISEASES  AND  INJURIES  OF  THE  EYE. 


brought  to  a  focus  at  a  point  behind  it;  if,  now,  a  screen  is 
placed  at  this  point,  an  inverted  image  of  the  candle  will  be 
formed  upon  it.  The  eye  may  be  considered  as  equal  to  a  bi- 
convex lens  of  I  of  an  inch  or  22.65  mm.  focal  length  by 
which  inverted  images  as  in  Fig.  9  are  formed  upon  the  retina 
as  a  screen.  Impressions  made  on  the  perceptive  elements, 
cause  local  changes,  the  effect  of  which,  when  transmitted  to  the 
brain,  is  projected  outwards  in  an  inverted  direction  to  the  object, 
thus  making  us  conscious  of  the  existence  of  the  form  and  posi- 
tion of  objects,  although  in  reality  we  only  see  the  inverted 
images  of  them.  Again,  the  fact  that  we  see  the  image  in  its 
proper  position,  instead  of  inverted,  is  explained  on  the  hy- 
pothesis that  each  cone  conveys  its  own  portion  of  the  retinal 

image  to  the 
brain.  For  the 
formation  of 
an  image  upon 
the  retina,  a 
^^-  9.  dioptric  appar- 

atus is  provided.  This  consists  of  a  series  of  curved  refracting 
surfaces  and  media,  which  are  sufficient  to  bring  rays  of  light 
to  a  focus  upon  the  retina,  and  thus  produce  a  well-defined 
image.  These  refractive  media  being  transparent  the  rays  of 
light  enter  the  outer  surface  of  the  cornea,  pass  through  the 
cornea,  the  aqueous,  the  lens  and  the  vitreous.  The  cornea, 
aqueous  and  vitreous  have  the  same  refractive  power  or  index, 
and  the  lens,  although  not  possessing  the  same  refractive  power 
throughout,  yet,  owing  to  the  difference  in  the  density  of  its 
central  and  outer  layers,  may  be  considered  as  having  a  refrac- 
tive power  equal  to  the  mean  of  the  sum  of  its  refractive  parts. 
'Thus,  for  the  purpose  of  demonstration,  the  natural  eye,  instead 
of  presenting  these  several  refractive  surfaces  and  media,  is  re- 
duced to  a  "diagrammatic  eye"  in  which  the  refracting  surfaces 
are  reduced  to  three,  viz. :  (1)  The  anterior  surface  of  the  cornea. 
(2)  The  anterior  surface  of  the  lens,  separating  the  aqueous 
from  the  lens.  (3)  The  posterior  surface  of  the  lens,  separating 
the  lens  from  the  vitreous.  The  media  are  similarly  reduced  to 


A  CCOMMODA  TION. 


15 


two:  the  mean  index  of  the  lens,  and  the  aqueous  or  the  vitreous. 
This  diagrammatic  eye  becomes  of  great  value  in  studying 
physiological  optics  where  the  calculations  deduced  represent 
those  of  the  natural  eye  with  sufficient  accuracy  for  practical 
purposes.  The  calculated  position  of  the  principal  posterior 
focus,  that  is,  the  point  at  which  all  rays  falling  upon  the 
cornea  parallel  to  tJae  optic  axis  are  brought  to  a  focus,  is  in 
the  diagrammatic  eye  14.647  mm.  behind  the  posterior  surface 
of  the  lens,  or  22.647  mm.,  about  23.  mm.,  behind  the  anterior 
surface  of  the  cornea.  The  fovea  centralis,  the  point  of  most 
acute  vision  of  the  retina,  must  occupy  this  position  in  order 
that  a  distinct  image  of  a  distant  object  may  be  formed  upon 
it.  The  values  given  in  these  calculations,  however,  refer  to 
the  eye  when  in  a  condition  of  rest  and  not  in  any  effort  of 
accommodation. 

ACCOMMODATION. 


Parallel  rays  of  light  entering  the  normal  eye  when  it  is  in 
a  state  of  rest,  are  brought  to  a  focus  upon  the  retina;  light- 
rays  coming  from  an  object  over  twenty  feet  distant  being 

sufficiently 
parallel  for 
all  practical 
purposes.  If, 
now,  these 
rays  are  ren- 
dered diver- 
gent, or  the 
^i»- 10-  o  b  j  e  c  t     i  s 

brought  nearer  to  the  eye,  the  rays  no  longer  form  an  image 
upon  the  retina,  but  at  some  distance  behind  it,  as  the  focal 
power  of  the  eye,  in  this  condition,  is  not  enough  to  bend  the 
rays  of  light  sufficiently  to  bring  them  to  a  point  upon  the 
retina;  hence,  for  the  purpose  of  producing  a  well-defined 
image  upon  the  retina,  when  an  object  is  within  an  infinite 
distance,   the    eye   possesses   the    power   to    adjust   itself   for 


16  DISEASES  AND  INJURIES  OF  THE  EYE. 

this  distance.  This  power  is  termed  the  function  of  accom- 
modation and  enables  the  eye  to  focus  near  objects  distinctly. 
This  is  accomplished  by  an  increase  in  the  convexity  of  the 
crystalline  lens  [A  Fig.  10),  chiefly  on  its  anterior  surface, 
whereby  it  becomes  a  lens  of  shorter  focus  [B  Fig.  10).  The 
lens  is  elastic  and  by  reason  of  a  peculiar  arrangement  of 
its  fibres  constantly  tends  to  assume  a  more  convex  shape. 
The  degree  of  convexity  is  controlled  by  the  tension  of  its 
suspensory  ligament,  the  zonule  of  Zinn,  acting  upon  its 
capsule.  In  the  act  of  looking  at  a  near  object  the  ciliary 
muscle  contracts  and  bringing  the  ciliary  processes  closer 
together  the  zonule  is  relaxed,  and  the  lens  becomes  at  once 
more  convex  fi'om  its  own  elasticity.  This  elasticity  dimin- 
ishes from  infancy  with  a  corresponding  diminution  in  the 
power  of  accommodation,  until  at  forty  years  of  age  it 
becomes  difficult  to  focus  for  a  near  point  for  minute 
objects.  During  the  act  of  accommodation,  which  is  an 
involuntary  one,  certain  other  changes  in  the  eye  take  place, 
and  the  whole  act  may  be  summed  up  as  follows:  the  pupil 
contracts,  cutting  off  the  more  diverging  rays,  the  front 
of  the  lens  becomes  more  convex,  and,  advancing  somewhat, 
carries  the  iris  forward  with  it;  the  posterior  surface  of 
the  lens  changes  slightly,  its  edges  becoming  rounded;  the 
ciliary  body  increases  in  size  and  projects  somewhat  nearer  to 
the  centre  of  the  eye.  The  main  factor  in  the  production  of  this 
adjustment  of  the  eye  is  the  ciliary  muscle,  the  ring  muscle  of 
the  ciliary  body,  which  on  contracting  becomes  thicker,  causing 
a  swelling  of  the  ciliary  body,  and  a  movement  of  this  process 
inward,  thus  relaxing  the  suspensory  ligament. 

The  eye  is  by  no  means  a  perfect  optical  apparatus,  but 
presents  many  defects  owing  to  the  curves  of  its  surface  not 
being  perfectly  spherical,  thus  producing  a  diffusion  of  the 
image  from  spherical  aberration,  or  there  may  be  a  want  of 
symmetry  in  the  curves,  as  in  astigatism.  The  media  also  are 
not  perfectly  transparent,  and  shadows  of  these  imperfections 
are  throAvn  upon  the  retina,  presenting  what  is  termed  entoptic 
phenomena. 


VISUAL  PURPLE.  17 

The  region  of  most  distinct  vision  is  the  macula  lutea,  and 
it  is  at  this  point  that  the  images  are  focused  upon  the  retina. 
Although  all  other  portions  of  the  retina  are  sensitive  to  light 
impressions,  the  images  diminish  in  distinctness  as  they  are 
removed  from  the  yellow  spot.  The  images  of  surrounding 
objects  which  are  visible  when  the  eye  is  fixed  in  any  direction 
constitute  the  field  of  vision.  The  region  of  distinct  vision  is 
limited,  however,  to  the  macula  lutea  where  only  cones  are 
present  as  terminal  elements  of  the  nerve  structure  of  the 
retina.  The  optic  nerve  entrance,  being  entirely  destitute  of 
the  rods  or  cones,  presents  a  blind  spot,  or  scotoma,  in  the 
field  of  vision,  thus  proving  that  the  optic  nerve  fibres  them- 
selves are  insensible  to  light.  The  size  of  this  blind  spot 
depends  upon  the  distance  of  the  field  of  vision  from  the  eye. 
At  eighteen  inches,  it  amounts  to  the  area  of  a  circle  of  one 
inch  in  diamter.  At  the  distance  of  the  moon,  this  scotoma 
covers  a  field  equal  to  thirteen  diameters  of  the  moon.  To 
demonstrate  this  loss  in  the  field  of  vision  the  experiment  of 
Mariotte  is  employed.  A  cross  is  made  on  a  sheet  of  paper, 
and  2f  in.  to  the  right,  is  drawn  a  black  disc  ^  in.  in  diameter. 
Closing  the  left  eye,  the  right  is  directed  at  the  cross  held 
about  one  foot  away.  On  moving  the  paper  to  and  from 
the  eye,  the  disc  will,  at  a  certain  distance,  become  invisible. 

VISUAL  PURPLE. 

The  discovery  by  Boll,  sustained  by  the  later  investigations 
of  Kuhne,  that  the  rods  of  the  retina  were  surrounded  by  a 
secretion  from  the  hexagonal  pigment  cells  of  the  retina,  of  a 
purple  or  rose  color,  which  is  formed  in  darkness  and  decom- 
posed in  sunlight,  was  supposed  to  determine  the  photo- 
chemical theory  of  light  perception  that  the  images  of  objects 
were  impressed  upon  the  retina  by  the  decomposition  of  this 
coloring  matter,  and  the  fact  that  these  images  could  be  so 
fixed  upon  the  retina  as  to  be  copied  after  death,  seemed  to 
add  weight  to  this  theory  of  the  origin  of  visual  impulses. 
The  discovery,  however,  that  the  rods  were  the  active  agents 

2 


18  DISEASES  AND  JNJUEIES  OF  THE  EYE. 

in  the  secretion  of  this  matter,  and  its  total  absence  from  the 
central  part  of  distinct  vision,  the  macula  lutea,  where  only 
cones  are  present,  shows  that  further  investigation  will  be 
required  to  determine  its  true  function. 

BINOCULAR  VISION. 

Though  we  have  two  eyes,  the  fact  that  we  have  binocular 
vision,  or  single  sight,  is  due  to  the  reception  of  the  image 
upon  symmetrical  portions  of  the  two  retinas,  which  contain 
cones,  the  centers  of  which  are  probably  centrally  asso- 
ciated in  the  brain.  To  effect  binocular  vision,  both  eyes 
converge  equally  upon  the  object,  and  images  are  formed  upon 
identical  portions  of  the  retina.  These  images  blended  in 
the  brain  give  us,  not  only  size  and  direction,  but  also  relief, 
or  the  idea  of  solidity,  of  the  object.  With  monocular,  or 
vision  with  a  single  eye,  we  get  only  an  idea  of  the  size  and 
direction,  but  not  of  the  solidity  of  the  object.  If  the  images 
do  not  fall  upon  identical  or  corresponding  portions  of  the 
retina,  as  the  fovea,  then  two  objects  are  seen,  and  double 
vision,  or  diplopia,  results. 


CHAPTEE    II. 

METHODS    OF    EXAMINATION. 

GENERAL  EXAMINATION. 

With  a  systematic  mode  of  examination  of  eye  patients, 
the  surgeon  quickly  acquires  the  habit  of  rapidly  diagnosing 
some  eye  affections  from  external  appearances,  thus  rendering 
the  result  of  complete  inquiry  into  the  full  condition  less 
liable  to  error.  The  history  and  symptoms  of  disease  or 
injury  of  the  eye  are  often  necessary  in  the  formation  of  a 
■diagnosis,  and  should  be  supplemented  by  a  personal  and 
careful  inspection  of  the  eye  and  its  appendages,  before 
formulating  an  opinion  or  proceeding  to  treatment.  A 
glance  at  the  appearance  and  bearing  of  the  patient  may 
enable  us,  in  some  cases,  to  decide  upon  the  part  affected, 
and  confirm  the  diagnosis  by  further  examination.  A  person 
having  lost  vision  from  some  retinal  or  optic  nerve  affection 
•carries  his  head  'well  up  and  eyes  open ;  the  cataract  patient 
shades  the  eyes  with  the  hand  and  advances  more  timidly. 
The  astigmatic  patient  carries  the  head  to  one  side,  or  with 
the  lids  half  closed,  as  in  myopia,  or  with  the  head  bent 
forward  and  the  eyes  directed  upwards  towards  the  eyebrows, 
as  in  paralysis  of  the  superior  oblique  muscle,  where  vertigo 
follows  the  attempt  to  look  downwards.  The  half-closed 
eyes  of  one  suffering  from  ptosis,  or  the  trachomatous  patient 
with  his  heavy  lids,  or  again  the  patient  suffering  from 
\some  corneal  or  conjunctival    affection  where  intense   photo- 

19 


20  DISEASES  AND  INJURIES  OF  THE  EYE 

phobia  requires  covering  the  eyes  to  exclude  all  light,  indicate 
the  part  affected  and  the  probable  diseased  condition. 

DETAILED  EXAMINATION. 

For  the  purposes  of  examination,  the  patient  should  be 
seated  before  a  window  which  admits  a  clear,  but  not  too 
bright  light;  the  surgeon  stands  at  the  side,  or  if  necessary 
to  confine  the  head  of  the  patient,  a  towel  having  been 
thrown  over  it,  it  is  supported  against  the  chest  of  the  sur- 
geon, who  stands  behind.  In  young  children  or  infants,  the 
body  and  limbs  of  the  child  should  be  held  in  the  lap  of 
an  attendant  while  the  head  rests  between  the  knees  of  the 
surgeon.  If  the  eyes  are  sensitive  to  light  and  painful,  or 
the  patient  so  nervous  as  to  interfere  with  a  proper  exam- 
ination, it  is  necessary  to  administer  an  anaesthetic,  as  a 
complete  inspection   must  be  obtained. 

In  a  general  survey,  we  are  obliged  to  determine  by 
comparison  of  the  two  eyes  whether  one  or  both  are  affected; 
the  presence  or  absence  of  squint,  or  loss  of  mobility  of  the 
eyes  from  paralysis  of  the  muscles  or  the  pressure  of  tumors 
from  behind. 

The  condition  of  the  lids  as  to  wounds,  scars,  loss  of  motion 
as  in  ptosis,  or  loss  of  power  to  close  them  as  in  facial 
paralysis,  inversion  or  e version  of  their  margins,  the  condi- 
tion of  the  cilia,  their  irregularity,  distribution  or  loss  should 
be  observed.  The  margins,  whether  normal  in  color  and 
thickness,  or  red,  ulcerated  and  thickened;  and  the  presence 
or  absence  of  tumors,  swellings,  or  styes. 

The  prominence  of  the  eyeball  with  loss  of  mo,tion  in  any 
direction  from  orbital  tumors,  Basedow's  disease,  etc.  The 
mobility  of  the  eye  being  decided  by  having  it  follow  a 
pencil  held  in  front  of  the  patient  and  moved  in  various 
directions. 

The  next  thing  to  be  done  is  fo  open  the  eyelids  to  gain 
a  view  of  the  front  of  the  eyeball.  This  is  done  by  placing 
the  thumb  upon  the  skin,  above  or    below  the  eye,  and   by 


DETAILED  EXAMINATION.  21 

gentle  traction  separating  the  lids.  This  must  be  carefully- 
done  so  as  not  to  give  pain,  or  by  making  too  much  pres- 
sure upon  the  eyeball  cause  its  rupture,  as  might  easily 
happen  in  cases  where  the  cornea  is  diseased.  It  will  become 
necessary  in  some  cases  to  use  metallic  retractors  which  are 
provided  for  the  purpose.  Upon  opening  the  eyes  the 
appearance  of  the  cornea  is  shown,  whether  normally  trans- 
parent or  exhibiting  the  presence  of  foreign  bodies,  maculae, 
or  partial  or  complete  clouding,  as  in  pannus,  pustular  ulcera- 
tions and  keratitis. 

If  the  eyes  are  inflamed,  determine  what  tissue  is  affected. 
If  it  is  the  conjunctiva^  notice  the  color,  amount  and  nature  of 
ihe  discharge,  whether  it  be  stringy,  muco-purulent,  or  puru- 
lent. If  only  one  eye  is  affected,  or  if  no  discharge  is  present, 
evert  the  eyelid  and  examine  for  some  foreign  body  which  may 
have  lodged  in  the  palpebral  folds.  The  lower  portion  of  the 
conjunctiva  is  easily  brought  into  view  by  pulling  the  lower  lid 
down.  An  examination  of  the  upper  portion  requires  the 
eversion  of  ihe  upper  lid,  which  is  readily  accomplished,  after 
a  little  practice,  by  seizing  the  eyelid  between  the  finger  and 
thumb,  and  drawing  it  away  from  the  globe,  at  the  same  time 
directing  the  patient  to  look  downwards,  while  the  third  finger 
or  a  small  probe-like  object  catches  the  upper  border  of 
the  tarsus  and  pressing  it  down  the  lid  is  everted,  and  its 
conjunctival  surface  and  the  upper  cul-de-sac  brought  into 
view.  At  a  glance  we  take  in  the  appearance  of  the  lower 
portion  of  the  conjunctiva,  noticing  whether  it  present  the 
normal  salmon  tint  and  is  smooth,  or  injected,  thickened  or 
granulated.  If  the  source  of  irritation  is  not  thus  revealed, 
we  may  find  it  in  the  closure  or  eversion  of  the  lachrymal 
puncta,  which,  instead  of  being  directed  towards  and  touching 
the  conjunctiva  of  the  ball,  are  turned  upward  or  outward. 

The  eye  may  present  a  suffused  appearance,  or  the  tear 
fluid  passes  over  the  lid  to  the  cheek,  when  pressure  upon  the 
sac-like  swelling  on  the  side  of  the  nose  near  the  inner  angle 
of  the  eye  will  cause  a  flow  of  pus  through  the  canaliculi 
into  the  eye,  thus  indicating  an  inflammation  and  stricture 
of  the  lachrymal  sac. 


22  DISEASES  AND  INJURIES  OF  THE  EYE. 

The  transparency  of  the  cornea,  the  presence  or  absence  of 
inflammatory  or  cicatricial  spots,  and  irregularities  of  surface 
must  be  determined  before  making  an  examination  of  the 
deeper  portions,  or  the  appearances  due  to  the  shadows  from 
irregularities  or  spots  upon  the  surface  may  cause  confusion 
when  projected  upon  the  lens  or  retina.  Touching  the  cornea 
with  a  bit  of  paper  will  reveal  at  once,  whether  it  possesses  a 
proper  degree  of  sensibility. 

The  color,  mobility  and  shape  of  the  iris  are  then  to  be 
noticed.  If  in  a  comparison  of  the  color  of  the  two  irides  we 
find  that  one  differs  in  color  from  the  other  and  the  eye  is 
inflamed,  iritis  should  be  suspected.  In  a  healthy  condition 
there  is  frequently  a  difference  in  the  color  of  the  two  eyes, 
as  one  may  be  gray  and  the  other  blue;  or  one  brown  and  the 
othef  yellowish  brown;  but  if  one  is  blue  and  the  other 
greenish,  we  should  look  for  inflammation,  either  present  or 
past,  of  its  structure.  To  determine  whether  tlie  pupil  dilates 
or  contracts  freely  under  the  stimulus  of  light,  the  patient  is 
placed  before  a  moderately  strong  light.  Covering  the  eye 
not  under  examination  with  one  hand,  the  other  is  passed 
back  and  forth  slightly  in  front  of  the  eye  to  be  tested,  while 
at  the  same  time  the  action  of  the  pupil  is  noted  from  the  side. 
If  the  iris  is  in  a  normal  condition,  it  will  dilate  as  the  hand 
shades  the  cornea  and  contract  the  moment  the  light  is  allowed 
to  strike  the  eye.  Any  loss  of  this  power  of  action  on  the 
part  of  the  iris  is  indicative  either  of  mechanical  obstruction, 
as  when  united  to  the  lens  capsule  by  present  or  former  inflam- 
mations, or  of  retina],  optic  nerve,  spinal,  or  cerebral  diseases. 
The  pupils  may  present  an  enlarged  and  inactive  condition, 
as  in  some  cases  of  loss  of  vision  in  glaucoma  and  paralysis  of 
the  third  nerve. 

The  character  of  the  pain  described  by  the  patient  will 
assist  more  frequently  in  deciding  our  prescription  than  in 
diagnosing  the  disease.  In  affections  of  the  conjunctiva 
the  sensation  is  usually  described  as  smarting,  burning, 
sandy,  or  as  if  the  eye  was  full  of  sticks,  etc.,  and  indicates 
usually  some   superficial   affection,    which   may,  however    be 


DETAILED  EXAMINATION.  23 

a  reflex  one.  Inflammation  of  the  cornea,  and  particularly 
of  the  iris,  presents  severe  pains,  and  an  aching  which  is 
only  rarely  assigned  to  the  eyeball,  more  frequently  affecting 
the  distribution  of  the  fifth  nerve  about  the  eye.  Pain 
deep  in  the  eye,  or  behind  the  orbit  is  often  an  accompani- 
ment of  asthenopic  troubles;  while  aching  over  the  eye  in 
the  forehead  and  eyebrow,  often  extending  back  into  the  head, 
is  an  indication  of  fatigue  of  the  accommodation,  or  some 
error  of  refraction,  as  astigmatism. 

From  the  vascularity  of  the  eyes,  valuable  information  may 
be  derived  from  a  close  inspection  of  the  distribution  of  blood- 
vessels upon  the  surface  of  the  eyeball.  The  vessels  of  the 
conjunctiva,  which  are  invisible  in  health,  present  a  bright  red 
injection  which  extends  up  to  the  cornea,  and  is  found  to  move 
with  the  conjunctiva  as  it  is  moved  over  the  globe  under  the 
pressure  of  the  finger  upon  the  edge  of  the  eyelid,  indicating 
the  presence  of  conjunctivitis.'  A  second  system  of  blood- 
vessels which  become  apparent  in  diseased  conditions  is  that 
of  the  anterior  ciliary  arterial  branches,  consisting  of  small, 
straight,  parallel  vessels  radiating  from  the  cornea,  which  are 
not  affected  by  any  motion  of  the  conjunctiva.  This  injection 
constitutes  a  pinkish  ciliary  zone  which  indicates  some  irrita- 
tion, as  a  foreign  body  upon  the  cornea,  or  ulceration  or 
inflammation  of  both  the  cornea  and  iris. 

It  becomes  necessary  to  ascertain  the  tension  of  the  eyeball 
in  cases  where  the  cornea,  iris,  ciliary  body,  or  choroid  are 
inflamed,  or  after  injuries.  Eyeball  tension  is  readily  obtained 
by  directing  the  patient  to  gently  close  the  eyelids  and  turn 
the  eyes  down,  when  the  tip  of  the  index  finger  of  each  hand 
is  placed  upon  the  eyeball  over  the  closed  lids  and  as  far  back 
on  the  sclera  as  possible ;  light  alternate  pressure  is  then  made 
by  the  tips  of  the  fingers,  when  the  eyeball  in  its  normal 
condition  is  felt  to  dimple  under  one  finger,  while  at  the  same 
time  a  direct  impulse  from  the  fluids  of  the  eye  is  given  to 
the  other  finger.  The  normal  tension  of  the  eyeball,  which  is 
indicated  by  the  symbol  Tn.,  differs  in  different  indi\dduals, 
and  at  different  times  in  the  same  individual.     The  tension 


24  DISEASES  AND  INJURIES  OF  THE  EYE. 

may  be  increased  or  lessened  according  to  the  amount  of 
secretion  which  is  retained  in  it.  The  degrees  of  tension  are 
given  as  T,  T+1,  T+2,  T+3;  indicating  first,  normal  tension, 
second,  slight  increase;  third,  decided  increase;  fourth,  stony 
hardness.  The  eye  at  times  shows  a  decreased  tension  as  in 
eyeball  atrophy  and  detachment  of  the  retina.  Here  the 
various  degrees  of  lessened  tension  will  be  indicated  by  the 
prefix  of -before  the  degree  of  T;  as  T-1,  T-2,  T-3.  In 
cases  of  doubt  the  interrogation  point  is  used,  as  T+  ?,  T—  ?. 

TEST  FOR  COLOE. 

It  becomes  necessary  in  our  diagnoses  to  test  the  color  per- 
ception, which  is  readily  accomplished  after  the  method  of 
Holmgren,  known  as  the  confusion  test.  This  consists  of 
matching  small  bundles  of  colored  worsteds  of  red,  orange, 
yellow,  green,  yellow-green,  blue,  blue-green,  violet,  purple, 
pink,  brown  and  gray.  The  patient  is  given  a  sample  of  the 
worsted  and  directed  to  select  from  the  balance  other  bundles 
of  the  same  shade  as  the  given  sample,  which  he  does  very 
readily  if  not  color-blind.  If,  however,  he  is  given  a  green 
sample  and  selects  red  or  gray  tints  and  places  them  with  the 
other,  the  color  perception  for  green  is  absent.  If  given  a 
scarlet  skein  and  he  takes  brown  or  dark  gray,  or  dark-green 
shades,  he  is  color-blind  for  red.  These  are  the  two  most 
common  forms  of  color-blindness.  Where  these  tests  are 
made  for  the  examination  of  railroad  and  steamboat  employes, 
instead  of  green  or  scarlet  skeins,  those  of  light  purple  or 
rose  color  should  be  used,  as  these  colors  are  composed  of  red 
and  blue.  The  red-blind  will  select  blue  shades  to  match 
with  them,  because  he  perceives  only  the  blue  in  the  purple, 
while  if  he  is  green-blind,  he  brings  only  the  green  sample  to 
match  the  purple. 

FIELD  OF  VISION. 

To  assist  in  diagnosing  certain  eye  affections,  such  as  glau- 
coma, hemiopia,  and  atrophy  of  the  optic  nerve,  it  becomes 


FIELD  OF  VISION.  25 

necessary  to  examine  the  power  of  the  eccentric  portions  of 
the  retina  to  perceive  objects.  In  the  normal  eye  when  the 
gaze  is  fixed  upon  an  object,  the  eye  being  at  rest,  not  only 
this  object  but  many  others  lying  within  a  circle  ^extending 
some  distance  about  it,  are  more  or  less  distinctly  seen.  A 
distinct  sharp  image  of  the  object  looked  at  is  formed  upon 
the  macula  lutea,  and  is  termed  central  or  direct  vision.  The 
images  of  surrounding  objects,  which  are  perceived  at  the 
eame  time,  are  focused  upon  the  portions  of  the  retina  beyond 
the  macula  lutea.  The  greater  the  distance  from  this  point 
to  the  place  where  they  are  focused,  the  less  distinct  they 
become.  This  is  termed  peripheral  or  eccentric  vision.  The 
extent  of  this  circle  is  termed  the  visual  field,  and  it  is  fre- 
quently important  to  determine  whether  the  normal  limits  are 
retained.  The  shape  of  this  space  is  oval  rather  than  circular, 
with  the  small  end  upwards,  and  the  fixation  point  lies  nearer 
to  the  nasal  side,  as  the  bridge  of  the  nose  interferes  with  the 
extent  of  vision  in  that  direction,  as  does  also  the  overhanging 
eyebrow  in  the  upward  direction.  Various  means  have  been 
devised  for  measuring  the  extent  of  the  visual  field.  Ingen- 
ious instruments  called  perimeters  have  been  invented  for  the 
purpose,  but  in  ordinary  practice,  a  blackboard  two  or  three 
feet  square  having  a  white  dot  in  the  center  will  be  sufficient. 
For  testing  the  visual  field,  the  patient  should  be  seated  before 
the  blackboard  so  that  the  eye  to  be  tested  is  about  twelve 
inches  from  the  surface  of  the  board  and  in  a  line  with  the 
centre,  then,  having  closed  or  covered  the  other  eye,  the  eye 
to  be  examined  is  directed  upon  a  cross-mark  in  the  centre  of 
the  board.  Then  the  surgeon  slowly  projects  a  piece  of  white  ' 
chalk  from  the  temporal  side  of  the  patient  until  he  perceives 
it,  when  a  mark  is  made  upon  the  board  at  that  point.  In 
this  way  the  chalk  is  earned  in  a  circle  around  the  centre  of 
fixation,  marking  the  most  extreme  points  which  the  patient  is 
able  to  see,  while  his  vision  is  concentrated  upon  the  dot. 
Lines  connecting  the  various  points  thus  made  upon  the 
blackboard  form  the  boundary  which  encloses  the  field  of 
vision.  It  may  be  roughly  taken  by  having  the  patient  close 
one  eye  and  with  the  other  look  at  a  button  upon  the  coat  of 


26 


DISEASES  AND  INJURIES  OF  THE  EYE. 


the  surgeon,  who  stands  in  front  of  him;  the  fingers  or  an 
object  held  in  them,  then  describes  the  circle,  which  is  mentally- 
registered  by  the  examiner  as  forming  the  limits  of  the  field 
of  vision  c^  the  patient. 

The  field  of  vision  for  colors  difiers  somewhat  from  that  for 
objects,  and  diminishes  in  size  for   the  various  fundamental 


White 

Blue 

Ked 

Green 


FIG  11. 


colors,  as  in  the  chart  Fig.  11,  from  blue  which  presents  tha 
largest  field,  through  yellow,  orange  and  red  to  green,  which 
has  the  smallest  visual  field.  The  color  field  may  be  mapped 
in  the  same  manner  as  above,  colored  chalks  beii^g  used 
instead  of  the  white. 


TESTING  THE  ACUTENESS  OF  VISION. 

To  determine  and  record  the  condition  of  the  vision,  which 
may  be  impaired  from  a  variety  of  causes,  it  was  necessary 
that  some  standard  of  comparison  should  be  agreed  upon. 
For  this  purpose  test  types  have  been  prepared  by  Snellen 
upon  a  definite  scale,  and  the  standard  thus  taken  is  the  power 


TESTING  T6E  ACUTENESS  OF  VISION.  27 

of  the  normal  eye  to  distinguisli  the  form  of  letters  which  in 
length  are  equal  to  the  measure  of  an  angle  of  five  minutes, 
and  the  limbs  of  the  letters  are  one-fifth  the  height  of  the 
letter  in  thickness,  thus  subtending  an  angle  of  one  minute  at 
a  distance  corresponding  to  the  number  of  the  letter.  These 
types  are  arranged  so  that  each  size  is  numbered  according  to 
the  distance  in  feet,  or  metres,  at  which  it  subtends  an  angle 
of  five  minutes.  Thus,  No.  1  is  seen  at  one  foot;  No.  XX  at- 
twenty  feet.  The  acuteness  of  vision,  denoted  by  the  letter  V, 
is  expressed  by  a  fraction  of  which  the  denominator  is  the 
number  of  the  type  and  the  numerator  the  number  of  feet  at 
which  it  is  seen.  For  example,  the  one  more  frequently  used 
is  No.  XX  of  Snellen,  which  should  be  seen,  in  a  well  lighted 
room,  at  twenty  feet.  If  these  letters  are  read  at  that  dis- 
tance, then  the  sharpness  or  acuteness  of  vision  is  expressed  as 
V=f^.  If,  however,  those  which  should  be  read  at  fifty  feet, 
are  alone  seen,  then  Y=:|^.  The  acuteness  of  vision  thus 
measured  is  not  always  accurate,  as  many  persons  have  the 
power  to  distinguish  letters,  say  of  No.  XX,  at  still  greater  dis- 
tances, but  this  test  is  sufficiently  approximate  for  all  practical 
purposes. 

If  the  vision  is  so  defective  that  the  larger  letters  can  no 
longer  be  distinguished  at  any  distance,  then  the  fingers 
should  be  held  between  the  patient  and  the  light,  and  the  dis- 
tance at  which  he  is  able  to  count  them,  noted.  If  the  visual 
acuteness  is  still  lower  than  this,  he  may  yet  be  able  to  deter- 
mine the  kind  and  color  of  reflected  light,  and  is  then  said  to 
have  only  qualitative  perception  of  light.  If,  however,  he  is 
only  able  to  distinguish  light  from  darkness,  or  notice  the  dif- 
ference between  light  and  shadow,  as  in  cutting  off  the  raya 
from  a  window  or  gas  jet  by  passing  the  hand  before  the  eyes, 
he  retains  only  quantitative  perception  of  light,  and  the  vision^ 
only  falls  short  of  absolute  blindness. 

RANGE  OF  ACCOMMODATION. 

The  examination  of  the  range  of  accommodation  consists  in 
measuring  the  distance  between  the  nearest  and  farthest  points 


28  DISEASES  AND  INJURIES  OF  THE  EYE. 

at  which  test  types  are  seen,  which  should  be  read  at  one  foot. 
Thus  No.  1^  of  Snellen  may  be  read  up  to  within  five  inches 
of  the  eye,  and  also  at  a  distance  of  eighteen  inches.  The 
difference  between  five  inches  and  eighteen  inches  gives  the 
range  of  accommodation,  Relaiive  accommodation  is  the  term 
applied  to  the  involuntary  association  of  the  accommodation 
with  the  convergence  of  the  optic  axis.  In  converging  the 
eyes  upon  an  object  at  a  foot  distant,  we  can  accommodate  for 
that  distance  or  lessen  or  increase  the  accommodation  without 
the  exertion  of  the  internal  recti  muscles,  or  without  changing 
their  position ;  the  part  which  can  be  increased  under  these 
circumstances  is  termed  the  positive  accommodation,  and  that 
which  can  be  lessened  without  changing  the  convergence  of 
the  eyes,  is  termed  the  negative  accommodation. 

FOCAL  ILLUMINATION. 

For  a  clinical  examination  of  affections  of  the  anterior  parts 
of  the  eye,  as  opacity  'of  the  cornea,  changes  in  the  iris, 
deposits  on  the  lens  in  the  pupil,  cataract,  pus  or  tumors 
which  have  extended  forward  into  the  vitreous,  the  oblique  or 
focal  illumination  is  applicable.  This  consists  in  converging 
the  rays  of  light  from  a  lamp  or  gas  jet,  in  a  partially  dark- 
ened room,  by  means  of  a  convex  lens  of  two  or  two  and  a 
half  inches  focus.  The  lens,  held  between  the  thumb  and 
finger,  is  used  as  a  burning  glass  and  brought  close  to  the  eye, 
BO  that  the  focused  rays  are  brought  to  bear  upon  the  part  to 
he  examined  in  an  oblique  direction.  Thus  the  cornea,  iris, 
lens  and  anterior  portion  of  the  vitreous  may  be  successively 
examined  by  varying  the  position  of  the  patient's  eye,  so  that 
the  focus  of  the  rays  will  fall  upon  the  part  to  be  inspected. 
If  desired,  the  pupil  may  be  dilated  with  atropine  to  give  a 
more  extended  view.  The  presence  of  minute  foreign  bodies 
projecting  from  the  cornea,  opacities  in  its  substance  and  their 
depth,  hemorrhage,  pus  or  tumors  immediately  behind  the 
lens,  may  thus  be  determined.     A  second  lens  may  be  held  in 


EXAMINATION  WITH  THE  OPHTHALMOSCOPE.  29 

front  of  tlie  eye  thus  examined,  which  will  give  a  magnified 
image  of  the  part  under  inspection. 

EXAMINATION  WITH  THE  OPHTHALMOSCOPE. 

For  an  examination  of  the  deeper  parts  of  the  eye,  as  the 
choroid,  retina  and  optic  nerve,  the  ophthalmoscope  must  be 
ased.  This  instrument,  which  was  invented  by  Helmholtz  in 
1851  and  since  improved  by  Coccius,  Eeute,  Liebreich, 
Kekoss,  Knapp,  Loring  and  others,  has  revolutionized  the 
science  of  ophthalmology  and  made  it  exact.  Owing  to  the 
depth  of  the  various  tissues  in  the  eye  and  the  smallness  of 
the  pupil  through  which  they  are  observed,  it  is  impossible  in 

their  normal 
condition  to 
examine  them 
with  the  un- 
-J.  aided  eye.  A 
tumor  within 
the  eye  some- 
times pushes 
forward  the 
parts  from  the  bottom,  the  pupil  no  longer  appears  black,  and 
certain  portions  of  the  interior  are  thus  made  visible.  The 
black  appearance  of  the  pupil,  which  was  once  supposed  to  be 
due  to  the  complete  absorption  of  the  light  rays  by  the  dark 
pigment  of  tho  interior  of  the  eye,  is  now  known  to  depend  upon 
the  optical  law  of  conjugate  foci.  The  rays  of  light  entering 
the  eye  pass  through  the  cornea,  aqueous,  lens  and  vitreous, 
which  together,  in  their  refraction  of  light,  may  be  considered 
as  a  single  lens.  When  the  eye  looks  at  a  gas  jet  placed  at  a 
short  distance  away,  the  rays,  projecting  into  the  interior,  will 
form  upon  the  retina  an  image  of  the  jet.  These  rays  are, 
however,  reflected  back  from  the  retina,  and  in  their  passage 
are  refracted  by  the  eye  until  they  meet  again  at  the  gas  jet, 
where  they  form  an  image  in  the  flame.  These  rays  of  light 
being  limited  by  the  size  of  the  pupil,  it  is  impossible  for  the 


:30 


DISEASES  AND  INJURIES  OF  THE  EYE. 


-eye  of  the  observer  to  catch  a  sufficient  number  of  them  to 
enable  him  to  sae  the  interior  of  the  eye,  and  if  his  eye  is 
placed  in  a  direct  line  with  the  light  coming  from  the  eye 
under  examination,  the  head  of  the  observer  at  once  cuts  oflF 
the  rays  from  the  source  of  illumination.  *If,  now,  a  piece  of 
plain  glass,  or  a  small  mirror  be  interposed  between  the 
■observer's  eye  and  the  eye  to  be  inspected,  as  shown  in  Fig. 
12,  and  the  light  reflected  into  the  eye  by  the  glass  or  mirror, 
the  interior  of  the  fundus  becomes  at  once  illuminated  and 
visible.  Eays  of  light  passing  through  the  pupil  and  refrac- 
tive media  are,  in  the  normal  eye,  brought  to  a  focus  upon  the 


/a; 


Tetina.  A  part  of  these  rays  are  absorbed  by  the  pigment  of 
the  retina,  while  the  major  portion  follow  the  same  course 
which  they  took  in  entering,  hence  the  pupil  appears 
black,  because  none  of  these  light  rays  reach  the  eye  of  the 
•observer.  If,  however,  the  examiner  places  before  his  eye 
a  piece  of  glass,  or  thin  plates  of  glass  {CD)  as  in  Helm- 
holtz's  ophthalmoscope  (Fig.  13),  at  such  an  angle  that 
the  light  coming  from  a  luminous  body  is  reflected  into 
the  eye  under  examination,  the  light  rays  in  their  return 
reach  the  glass  reflector,  and  a  portion  of  them  pass 
through  to  enter  the  eye  of  the  surgeon  at  A,  and  the 
pupil    no    longer   appears   black,    but    brilliantly   red ;   this 


KINDS  OF  OPHTHALMOSCOPE.  31 

is   the    essential   principle   upon  which   the    ophthalmoscope 
depends. 

KINDS  OF  OPHTHALMOSCOPE. 

The  ophthalmoscope  consists  essentially  of  a  mirror  set  in 
a  handle,  a  convex  object  lens,  and  a  small  ocular  lens  held  in 
a  groove  behind  the  mirror,  as  in  Liebreich's  (Fig.  14),  or  con- 
tained in  disks  as  devised  by  Bekoss  which  rotate  upon  each 
•other  to  furnish  a  large  number  of  lenses  of  dijfferent  degree, 
as  in  those  of  Loring  and  Knapp,  for  the  measurement  of 
errors  of  refraction.  The  ordinary  requirements  of  the 
•ophthalmoscope,  largeness  of  the  field  of  view  with  good 
illumination,  are  well  met  in  the  small  ophthalmoscope  of 
Xiebreich   (Fig.  14),   which  consists  of  a  concave  mirror  of 

about  seven  inches  focal 
length  with  a  central 
opening,  attached  to  a 
short  handle.  The  back 
of  the  mirror  is  pro- 
-v^xt«K»K^w.        '^^1^^'  vided  with  a  clip  for 

holding  the  necessary 
correcting  lenses.  Unfortunately  they  are  usually  so  poorly 
made  as  to  be  almost  useless.  To  keep  pace  with  the  advance- 
ment of  ophthalmic  science,  more  compendious  instruments 
called  Refraction  Ophthalmoscopes  have  been  devised  by 
Wecker,  Loring,  Knapp  and  many  others;  the  principle  mod- 
ifications consist  in  the  substitution  of  detachable  or  revolving 
disks  containing  numerous  correcting  glasses,  for  the  former 
clip,  and  changes  in  the  size  and  shape  of  the  mirror  and 
its  perforation.  In  the  Loring  instrument  (Fig.  15)  the 
mirror  is  concave  and  made  very  thin,  with  a  focal  length 
of  seven  inches  and  a  central  perforation  6  mm.  in  diameter. 
The  handle  is  made  long  so  that  in  holding  it  the  observer's 
hand  does  not  come  in  contact  with  the  patient's  face  in 
the  direct  examination.  The  correcting  glasses  are  held  in 
disks  which  fit  in  a  cell  at  the  back  of  the  instrument 
and  are  retained  by  means  of  springs,  so  that  they  may  be 


32  DISEASES  AND  INJURIES  OF  THE  EYE. 

rotated  in  such  a  manner  that  the  center  of  the  glass  comes 
opposite  the  center  of  the  hole  in  the  mirror.  Less  elaborate 
and  equally  good  instruments  have  been  devised  by  Loring 
for  ordinary  ophthalmoscopic  work.  These  consist  of  a  single 
revolving  disk  with  perforations  for  twelve  or  sixteen  convex 
and  concave  lenses^  one  space  being  left  open  to  use  when  no 
correcting  glass  is  necessary,  and  furnish  a  very  satisfactory 

instrument  for  students  and  gen- 
eral practitioners.  Loring  has 
added  many  other  modifications 
to  his  instruments,  as  in  covering 
the  disks,  and  the  substitution  of 
a  tilting  mirror  of  a  parallelogram 
shape  instead  of  circular.  Knapp's 
double  disk  ophthalmoscope  con- 
sists of  the  ordinary  concave  re- 
flecting mirror  as  in  Liebreich's, 
Loring' s  and  others,  but  with  a 
perforation  3.75  mm.  in  diameter. 
This  is  screwed  on  a  thin  plate 
of  metal.  On  the  other  side  of 
this  metal  plate  are  two  disks,  of 
which  the  upper  contains  the  con- 
vex lenses  and  the  lower  a  similar 
series  of  concave  lenses.  Each 
disk  rotates  on  a  central  pivot  and 
^^"  ^'  presses  upon  a  delicate  spring  with 

a  point-like  elevation  at  the  end,  which  fits  into  corresponding 
depressions  in  the  disk,  which  arrest  the  disk  when  the  lens 
which  we  want  is  opposite  the  centre  of  the  aperture  of  the 
mirror.  The  two  disks  are  covered  by  a  metal  cover  which 
prevents  the  soiling  of  the  lenses.  The  disks  overlap  at  their 
margins  in  such  a  way  that  each  convex  glass  can  be  covered 
by  a  concave  glass.  Thus  combinations  are  formed  and  an 
extensive  series  of  lenses  obtained.  The  disks  are  rotated  in 
position  by  the  finger  tip  applied  to  the  top  and  side  of  the 
instrument.      Apertures  in  the  back  enable  us  to  read  the 


KINDS  OF  OPHTHALMOSCOPE. 


83 


numbers  of  the  lenses  which  are  behind  the  opening  in  the 
mirror.  A  short  ivory  handle  screws  into  a  socket  in  the 
mirror  plate. 

The  single  disk  instrument  of    Knapp   (Fig.  16)   is  very 
similar  to  Loring's  smaller  instrument.      The  disk  contains  an 


FIG.  16. 


empty  hole  and  twenty -three  or  more  lenses  which  are  covered 
by  metal,  and  is  easily  rotated  by  the  finger  without  losing 
the  ophthalmoscopic  image  for  the  time. 

3 


84  DISEASES  AND  INJURIES  OF  THE  ^EYE. 

THE  USE  OF  THE  OPHTHALMOSCOPE. 

Direct  Method, — A  well-darkened  room  should  be  pro- 
vided, with  a  good  light  from  an  argand  lamp,  or  gas  jet, 
which  should  ba  above  or  at  one  side  and  a  little  behind  the 
patient,  so  that  his  face  is  in  the  shadow.  The  light  should 
not  be  too  intense,  as  the  strong  reflection  causes  too  great 
contraction  of  the  pupil  and  fatigues  the  patient.  To  acquire 
the  skill  necessary  to  see  with  the  ophthalmoscope,  frequent 
examinations  should  be  made  upon  healthy  eyes,  as  the  instru- 
ment can  only  be  used  with  satisfaction  after  much  practice. 
The  patient  should  be  feeated  in  front  or  to  the  side  of  the 
surgeon,  the  light  being  to  one  side  of  the  patient  and  on  a 
level  with  his  eye,  so  that  the  eyes  of  both  are  on  the  same 
plane.  If  the  left  eye  is  under  observation,  the  surgeon  holds 
between  thumb  and  fingers  the  handle  of  the  ophthalmoscope, 
with  the  mirror  in  front  of  his  left  eye,  and  resting  the  upper 
edge  upon  the  under  side  of  the  eyebrow.  The  light  is 
reflected  by  the  mirror  into  the  eye.  Now  if  the  eye  of  the 
patient  and  also  the  eye  of  the  observer  are  possessed  of 
normal  refraction  and  the  accommodation  relaxes,  the  pupil 
appears  illuminated  at  once,  and  the  red  reflection  from  the 
fundus  is  obtained.  The  condition  of  the  lens  and  trans- 
parency of  the  vitreous  are  noAV  examined.  The  beginner  may 
be  satisfied  if  this  much  is  obtained  during  the  first  attempts 
with  the  use  of  the  instrument.  If,  now,  the  patient's  eye  is 
directed  upwards  slightly,  the  color  of  the  reflection  is 
changed  to  yellow  by  the  light  falling  upon  the  optic  disc, 
which  is  much  lighter  in  color  than  the  other  portions  of  the 
fundus.  Having  now  approached  still  closer  to  the  eye  until 
the  faces  almost  touch,  the  arteries  and  veins  upon  the  disc 
become  plain  and  the  details  of  the  fundus  are  carefully 
studied  out.  The  image  thus  seen  in  the  direct  method,  is 
not  a  real  image,  but  a  virtual  erect  image  which  appears  as  if 
situated  some  distance  behind  the  patient's  retina.  If,  at  any 
time  during  the  examination,  the  obsers^er  exerts  his  accommo- 
dation,  or    places   a   glass    behind    the    mirror    the    image 


THE  USE  OF  THE  OPHTHALMOSCOPE.  35 

disappears.  The  direct  image  on  tlie  retina  is  seen  by  this 
method  only  when  the  eye  of  the  patient  and  that  of  the 
observer  are  of  normal  refraction,  when  the  eye  of  the  patient 
is  hypermetropic  and  the  observer's  myopic  to  the  same 
degree,  or  when  the  patient  has  a  myopia  which  is  counter- 
balanced by  a  similar  degree  of  hypermetropia  in  the  surgeon. 

The  use  of  convex  glasses  behind  the  mirror  produces  an 
artificial  myopia  in  the  eye  of  the  observer,  while  concave 
lenses  similarly  applied  produce  artificial  hypermetropia.  The 
use  of  the  ophthalmoscope  in  determining  the  degree  of  the 
errors  of  refraction  will  be  discussed  in  the  chapter  devoted 
to  the  errors  of  refraction. 

With  the  direct  method  the  beginner  may  have  much  diflS.- 
culty  in  relaxing  his  accommodation,  owing  to  the  close  prox- 
imity of  the  eyes.  This  may  be  overcome  by  the  use  of  a 
convex  glass  behind  the  mirror  until  he  has  acquired  the 
knack  of  relaxing  his  accommodation.  With  the  examination 
by  this  method  a  larger  image  is  obtained  than  with  the  other 
and  the  exact  position  of  the  lesions  of  the  fundus  is  more 
accurately  determined.  The  extent  of  surface  of  the  fundus 
seen  at  any  one  time  is  less  than  with  the  indirect  method  and 
depends  upon  the  distance  between  the  two  eyes.  At  15  mm. 
it  equals  the  size  of  the  pupil.  The  nearer  the  eyes  af>proach 
the  larger  the  field ;  the  farther  removed,  the  smaller  the  field. 
If  the  eye  examined  is  not  normal  but  hypermetropic,  then  a 
convex  glass  equal  to  the  degree  of  hyperopia  must  be  used 
behind  the  mirror  before  the  fundus  becomes  distinct.  If  a 
normal  eye  examines  a  myopic  eye,  then  a  concave  lens  of  the 
degree  of  nearsightedness  must  be  used.  In  each  of  these 
cases  the  image  is  less  magnified  than  in  the  normal  eye,  but 
is  larger  in  the  myopic  than  in  the  hypermetropic  eye. 

Indibect  Method. — The  position  of  the  patient  and  sur- 
geon are  the  same  as  in  the  foregoing  method,  but  their  heads 
are  separated  to  a  distance  of  eighteen  to  twenty-four  inches. 
The  ophthalmoscope,  with  a  convex  lens  of  sixteen  or  twenty- 
four  inches  focus  in  position  behind  the  hole  in  the  mirror, 
is  slightly  turned  toward  the  light  so  that  the  reflection   is 


36  DISEASES  AND  INJURIES  OF  THE  EYE. 

thrown  into  the  eye,  and  the  red  reflexion  of  the  pupil  made 
apparent.  With  the  left  hand,  a  convex  lens  {L  Fig.  17) 
of  two  and  a  half  or  three  inches  focus  is  held  between 
the  thumb  and  fore-finger  parallel  to  the  front  of  the  eye,  the 
third  finger  resting  upon  the  median  line  of  the  forehead  of 
the  patient  and  giving  support  to  the  hand,  while  the  little 
finger  can  be  employed  to  raise  the  lid  if  necessary.  The 
lens  is  thus  held  about  two  inches  in  front  of  the  eye,  so  that 

the  rays  of 
light  reflect- 
ed on  the 
mirror  of  the 
ophthalmo- 
scope are  fo- 
cused by  the 
^®-"-  convex  lens 

in  the  pupil.  The  patient  is  now  directed  to  look  in  a 
direction  past  the  surgeon's  ear,  which  brings  the  optic  disc 
in  a  line  with  the  pupil,  and  on  moving  the  head  nearer  or 
removing  it  farther  from  the  eye  under  examination,  a  whitish 
object  appears  in  the  illuminated  pupil.  Slight  variations  in 
the  position  of  the  head,  mirror  or  lens,  which  must  be 
acquired  by  practice,  enable  the  surgeon  to  obtain  a  clear 
and  well  defined  image  of  the  entrance  of  the  optic  nerve 
into  the  eye,  and,  following  the  course  of  the  arteries  and 
veins  in  their  ramification  through  the  fundus  from  this 
point,  the  whole  of  the  interior  can  be  studied  by  having 
the  patient  move  the  eye  in  various  directions.  The  image 
now  seen  is  a  magnified  real  and  inverted  image  (a  Fig. 
17),  which  is  really  formed  in  the  air  between  the  ophthalmo- 
scope and  the  lens  held  before  the  eye  of  the  patient.  The 
size  of  the  image  depends  upon  the  object  glass  used,  and 
upon  the  refi'action  of  the  eye.  If  a  three-inch  lens  is  used 
and  the  eye  normal  the  increase  is  five  and  a  half  diameters. 
If  the  eye  is  hyperopic,  it  will  be  larger,  if  myopic,  smaller 
than  with  the  normal  eye.  The  image  thus  seen  can  be 
further  enlarged  by  using  a  weaker  convex  object  glass,  say 


OPHTHALMOSCOPIC  APPEARANCE  OF  NORMAL  FUNDUS.      37 

s.  four-inch,  which  must  be  held  farther  from  the  eye  of 
the  patient,  and  also  still  further  increased  by  having  a 
stronger  convex  lens  behind  the  mirror,  say  one-eighth. 

OPniHAiMOSCOPIC  APPEARANCE  OF   THE  N0R:MAL 

FUNDUS. 

The  cornea,  aqueous,  lens  and  vitreous  in  the  healthy  eye, 
Toeing  perfectly  transparent,  are  invisible  and  present  no 
reflex  under  examination  with  the  ophthalmoscope.  The 
fundus  of  the  healthy  eye  when  brought  into  view  through 

the  pupil,  presents  a  reddish-orange 
reflection  in  blonde  people  where  the 
retinal  pigment  is  not  sufficiently 
deep  to  prevent  the  reflection  of  the 
light  from  the  choroidal  vessels.  In 
brunettes,  the  pigment  being  darker, 
these  vessels  are  obscured,  and  the 
light  reflected  from  the  pigment 
through  the  retina  gives  it  a  grayish 
color.  The  fundus  of  the  eye,  when 
"viewed  by  the  ophthalmoscope,  presents  for  examination, 
first,  the  opiio  disc  (Fig.  18),  or  entrance  of  the  optic 
nerve.  This,  when  the  patient  is  looking  in  the  proper  direc- 
tion, changes  the  red  reflection  of  the  interior  to  a  whitish  hue 
which  fills  the  pupil  and  presents  a  well-defined  outline.  This 
light  color  is  due  to  the  absence  of  the  choroid  and  retina  at 
this  point.  Around  this  disc  is  a  still  whiter  collar,  due  to 
the  scleral  fibres  surrounding  the  entrance  of  the  optic  nerve, 
and  termed  the  scleral  ring.  In  other  cases  this  circle 
presents  a  dark  or  black  appearance  due  to  the  retinal 
pigment,  and  is  termed  the  choroidal  ring.  At  times,  this 
pigment  forms  only  a  segment  or  crescent.  These  pigmen- 
tary deviations  are  not  to  be  mistaken  for  pathological 
changes.  The  surface  of  the  disc  frequently  presents  a  more 
or  less  opaque  white  portion,  which  is  due  to  a  depression  of 
the  central  portion  of  the  nerv^e,  and  is  termed  the  physiology 


38 


DISEASES  AND  INJURIES  OF  THE  EYE. 


real  ecccavafion.  It  varies  in  size,  but  rarely  occupies  the 
whole  extent  of  the  disc,  and  should  not  be  confounded  -with 
the  cupping  which  occurs  from  pressure,  as  in  glaucoma. 
Upon  the  disc,  vessels  are  seen  emerging  at  or  near  its 
centre.  These  are  the  central  artery  and  vein  of  the  retina. 
The  artery,  which  is  smaller  and  of  a  light  red  dolor,  and 
presents  a  double  contour  or  light  streak  along  the  centre, 
usually  divides  into  two  branches,  one  running  upward,  while 
the  other  takes  a  downward  course,  again  dividing  and  rami- 
fying through  the  retina.  The  veins,  which  are  larger  and  of 
a  darker  color  and  more  tortuous,  are  usually  three  in  number : 
two  coming  from  below  and  one  from  above,  and  uniting  in 
the  centre  to  form  the  central  vein. 

Further  inspection  of  the  disc  shows  smaller  vessels  upon 
its  outer  portions.  These  are  nutrient  capillaries,  and  give 
to  it  the  reddish  appearance.  The  retina  being  perfectly 
transparent,  nothing  is  seen  except  the  ramifications  of  the 
arteries  and  veins  which  sweep  off  from  the  optic  disc. 
Possibly,  slight,  fine  lines  near  the  disc  and  along  the  main 
branches  of  the  vessels  may  be  apparent  and  are  due  to 
slight  opacities  in  the  optic  nerve  fibres.  In  brunettes  or 
negroes  the  retina  presents  a  bluish  film  which  is  more 
apparent  near  the  optic  nerve,  where  the  retina  is  thicker. 
If  the  retina  'appears  hazy,  the  difiiculty  may  be  due  ta 
want  of  transparency  in  the  cornea,  lens  or  vitreous.  This, 
of  course,  should  be  determined  before  further  examination 
of  the  retina.  The  choroid,  from  its  large  vascular  supply, 
gives  to  the  fundus  its  red  tint,  but  nothing  is  seen  of  it 
with  the  ophthalmoscope,  except  that  where  the  retinal  pig- 
ment is  abnormal,  the  outlines  of  the  venae  vorticosf©  and 
of  the  choroidal  vessels  become  apparent.  If  the  pigment 
layer  is  thin,  as  in  blondes,  or  absent,  as  in  Albinos,  then 
the  choroidal  vessels  become  visible  and  present  a  striking 
picture.  These  vessels  are  easily  distinguishable  from  those 
of  the  retina,  as  they  present  a  lighter  appearance,  are  much 
larger,  not  traceable  to  the  optic  disc,  and  present  no  light 
streak.     The  macula  lutea  and  the  fovea  centralis,  its  minute 


KERATOSCOPY.  39 

depression,  are  examined  with  difficulty  unless  the  iris  and 
the  accommodation  are  paralyzed  by  atropine,  as  it  lies  in 
the  direct  line  when  the  patient  looks  at  the  hole  in  the 
mirror,  and  the  exercise  of  the  accommodation  and  the 
consequent  contraction  of  the  pupil  and  the  puzzling  reflec- 
tions, prevent  its  being  observed  in  more  than  one-third  of 
the  cases  examined.  It  appears  as  a  minute  red  spot,  some- 
times surrounded  by  a  yellowish  or  whitish  ring;  the  latter 
is  more  frequently  observed  in  dark-complexioned  children. 
The  absence  of  any  change  in  the  retina  more  frequently 
determines  its  normal  condition  than  the  appearance  of  the 
part  itself.  The  sclera  is  not  seen  in  an  examination  of 
the  fundus,  unless  the  choroid  has  been  destroyed  or 
atrophied,  when  it  appears  of  a  glistening  white  at  the 
point  of  lesion. 

KERATOSCOPY. 

Keratoscopy  is  an  additional  method  of  examination  which 
has  been  recently  introduced  for  determining  the  refraction 
of  the  eye,  and  requires  for  its  application  a  concave  oph- 
thalmoscopic mirror.  The  patient  may  be  seated  about  forty 
inches  distant,  with  the  light  to  one  side,  so  that  it  falls 
upon  the  mirror  and  is  reflected  into  the  pupil  of  the  eye 
to  be  examined  in  a  very  oblique  direction.  Looking  through 
the  perforation  of  the  mirror  a  red  reflection  is  obtained, 
and  approaching  or  removing  farther,  a  clearly  defined 
image  is  formed;  this  image  is  surrounded  by  a  dark  shadow 
and  moves  with  any  rotation  of  the  mirror.  The  observer's 
eye  must  be  normal,  or  corrected  by  a  suitable  glass  behind 
the  mirror,  and  then  upon  rotation  of  the  mirror  the  image 
and  shadow  will  be  found  to  move  in  the  opposite  direction 
if  the  eye  be  hypermetropic,  emmetropic  or  slightly  myopic. 
If  the  eye  is  more  myopic  the  image  and  shadow  move  in 
the  same  direction  as  the  rotation  of  the  mirror.  To  deter- 
mine the  amount  of  the  error,  lenses  are  rotated  behind  the 
mirror,  until,  in    the   cas3    of    hyperopia,  the    image    moves 


40  DISEASES  AND  INJURIES  OF  THE  EYE. 

■with  the  rotation  of  the  mirror.  The  glasses  prescribed  by 
this  method  are  always  stronger  than  the  practical  glass, 
and  it  is  not  likely  to  supersede  the  more  exact  method  of 
Ophthalmoscopy. 


CHAPTEK     III. 

GENERAL  CONSIDERATIONS  OF   TREATMENT. 

USE   OF  ANESTHETICS. 

In  regard  to  the  use  of  anaesthetics,  it  may  be  said  that 
while  many  operations  upon  the  eye  are  excessirely  painful, 
there  are  also  many  which  are  not  so,  but  seem  very  alarming 
to  the  patient,  and  the  nerrous  anxiety  accompanying  the 
announcement  that  an  operation  of  any  kind  is  necessary  is 
sufficient  to  deprive  them  of  self-control.  Even  if  an  imme- 
diate consent  is  obtained,  the  patient  is  oftentimes  unable  to 
withstand  even  a  very  minor  operation  upon  the  eyeball,  as 
the  motor  muscles  are  but  slightly  under  control  of  the  will 
under  these  circumstances,  and  unless  the  utmost  care  and 
patience  are  exercised  by  the  surgeon,  the  agitation  of  both 
the  eye  and  the  patient  are  apt  to  so  interfere  with  the  opera- 
tion as  to  render  his  skill  less  likely  to  achieve  a  favorable 
result.  For  the  many  delicata  operations  upon  the  eye  it  is 
much  better  to  render  it  perfectly  passive  by  the  use  of 
anaesthetics  and  thus  prevent  any  spasmodic  movement  of  the 
eye,  or  sudden  compression  of  the  ball  by  the  sudden  closure 
of  the  lids,  during  or  at  the  close  of  the  operation.  In  regard 
to  the  choice  of  anajsthetics  the  author  believes  that  ether, 
while  consuming  more  time  in  its  administration,  is  otherwise 
as  suitable  for  all  operations  upon  the  eye  as  chloroform  and 
presents  much  less  risk. 

41 


42  DISEASES  AND  INJURIES  OF  THE  EYE. 

BANDAGING. 

In  diseases  or  injuries  of  the  eye  absolute  rest  of  the  part 
may  be  necessary  for  the  purposes  of  healing,  for  the  friction 
of  the  lids  as  they  move  over  the  cornea  or  conjunctiva  may 
become  not  only  painful  but  injurious.  For  the  purpose  of 
preventing  the  movements  of  the  eye  and  thus  securing 
perfect  rest  during  the  process  of  repair  a  bandage  is  used. 
This  may  be  of  two  kinds,  compress  or  pressure  and  retaining 
bandage.  A  compress  bandage  is  applied  after  first  covering 
the  eyelids  with  a  small  square  of  thin  linen  or  muslin,  and 
picked  lint  (charpie),  absorbent,  or  borated  cotton,  placed  bit 
by  bit  upon  this  in  such  a  manner  as  to  fill  up  all  the  irregu- 
larities of  the  surface  to  a  level  with  the  brow,  the  lighter 
portion  of  the  packing  coming  upon  the  lids  over  the  most 
prominent  portion  of  the  eyeball.  The  bandage  is  made  of  a 
strip  of  soft  flannel  or  merino  1^  inches  wide  and  1|  yards 
long  and  rolled.  When  both  eyes  are  to  be  bandaged  the 
length  must  be  increased  to  3i  yards.  In  its  application  the 
free  end  of  the  roller  is  applied  to  the  temple  on  the  side  of 
the  affected  eye,  and  the  roller  is  then  carried  around  the 
head  to  the  starting  point.  It  is  now  carried  down  obliquely 
across  the  occiput  and  under  the  ear  and  then  brought  up 
over  the  covered  eye  with  slight  tension  of  the  edge  of  the 
roller  nearest  the  nose,  pinned  to  the  layer  on  the  forehead, 
reversed  and  carried  above  the  ear,  thence  down  across  the 
occiput  and  up  over  the  eye  as  before,  tension  being  made  this 
time  upon  the  outer  edge  of  the  bandage  and  pinned  as  before, 
the  roller  turned  and  the  end  secured  by  pinning  above  the 
ear.  If  desired,  a  third  layer  may  be  applied  to  the  eye. 
When  both  eyes  are  to  be  covered  the  double  pressure  ban- 
dage is  applied  in  the  same  way  except  that  the  bandage  is 
laid  flatter  and  after  the  first  layer  has  been  brought  to  the 
median  line  of  the  forehead  the  pin  is  put  in  horizontally,  the 
roller  reversed  and  carried  down  over  the  second  eye  so  that 
the  inner  layer  of  the  bandage  of  the  first  eye  becomes  the 
outer  layer  of  the  second,  and  is  passed  down  under  the  ear 


BANDAGING.  4:i$ 

and  below  the  occiput  and  brought  up  under  the  ear  and  over 
the  first  eye,  reversed  to  cover  the  second  eye  and  the  end 
secured  as  before.  After  removal  of  the  eyeball  or  the 
contents  of  the  orbit,  the  packing  should  be  more  solid  and 
the  bandage  applied  with  greater  pressure.  A  figure  eight 
bandage  may  be  used  for  the  same  purpose ;  the  end  of  the 
roller  is  applied  at  the  median  line  of  the  nape  of  the  neck, 
and  passed  forward  over  the  face  on  either  side  as  desired, 
and  along  the  line  of  the  nose  and  across  the  root  of  the  nose 
to  the  other  side,  thence  over  the  occipital  prominence,  then, 
around  and  over  the  second  eye,  down  the  face  to  the  back  of 
the  neck  opposite  the  beginning.  Continue  in  this  way  until 
two  lines  of  bandage  are  laid  on  each  eye  and  then  the  balance 
carried  across  the  head  and  pinned.  Difficulty  is  experienced 
in  keeping  any  form  of  the  bandage  in  position  for  any  length 
of  time,  and  extra  pinning  or  stitching  together  will  be  neces- 
sarj.  The  wearing  of  a  light  knit  night-cap  over  the  bandage 
will  often  serve  an  excellent  purpose  in  retaining  it  in  proper 
position. 

As  the  condition  of  the  eye  improves,  or  when  it  is  neces- 
sary to  make  frequent  applications  to  it  a  retaining  bandage  is 
substituted  for  the  pressure  bandage.  A  convenient  form  ia 
made  of  one  or  two  thicknesses  of  muslin  2£  inches  wide  by  7 
inches  long,  either  square  or  tapering  at  the  ends  to  which 
tapes  are  attached.  Two  tapes  are  fastened  at  one  end  and 
one  at  the  other.  The  bandage  is  to  be  applied  diagonally 
across  the  eye  which  has  been  covered  with  a  bit  of  soft  linen, 
upon  which  is  placed  a  small  mass  of  absorbent  cotton;  one 
tape  from  each  end  is  carried  to  the  back  of  the  head,  crossed, 
brought  forward  and  tied  in  front,  while  the  remaining  tape  ia 
carried  below  the  ear  on  the  side  of  the  well  eye,  around  to 
the  back,  thence  over  the  top  of  the  head,  and  pinned  where  it 
crosses  the  others. 

For  retaining  icet  di^essings  on  the  eye  a  muslin  bandage  1£ 
inches  wide  and  1  yard  long  is  required.  It  is  used  in  the 
following  manner:  Begin  at  the  top  of  the  ear  and  pass 
up  a  little  in  front  of  the  vertex  and  then  around  the  head 


44  DISEASES  AND  INJURIES  OF  THE  EYE. 

Tjelow  the  occiput,  and  with  the  finger  beneath  the  bandage 
above  the  ear,  draw  firmly  and  pin ;  the  loose  end  of  the  ban- 
dage is  then  carried  over  the  compress  and  pinned  to  the  head 
l)and.     For  both  eyes  a  right-angled  head  bandage  is  used. 

EYE  SHADES. 

For  simple  protection  of  the  eyes  from  direct  light,  colored 
protective  glasses  made  of  plain  tinted  glass,  preferably  the 
smoke-tint,  may  be  used,  the  tint  to  be  determined  by  the 
nature  of  the  case.  For  more  full  protection  eye  shades  made 
of  card-board  and  covered  with  black  silk  are  very  comforting 
to  the  patient  in  many  cases  and  allow  of  his  taking  the  exer- 
cise which  may  be  needful  in  hastening  recovery. 

COLD  AND  HOT  APPLICATIONS. 

There  are  many  conditions  of  the  eye  where  the  application 
of  cold  or  heat  alleviates  pain,  retards  reaction  or  promotes 
Tesolution.  These  may  be  wet  or  dry  according  to  the  neces- 
sities of  the  case.  The  temperature  of  the  applications  may 
usually  be  left  to  the  choice  of  the  patient.  The  time  of  the 
application  is  to  be  regulated  by  its  effect  and  the  severity  of 
■the  inflammatory  process.  As  a  rule  it  is  better  to  apply 
ihem  only  for  a  few  minutes,  or  half  an  hour,  rarely  an  hour, 
and  then  after  an  inters'^al  of  half  an  hour,  an  hour,  or  longer 
Te-apply  them.  During  the  interval  the  eye  is  to  be  cleansed 
and  a  bandage  applied  if  necessary. 

For  cold  applications  wet  compresses  can  be  used,  formed  of 
several  thicknesses  of  old  linen  soaked  in  cold  water,  or  laid 
Tipon  a  large  piece  of  ice  in  a  basin  near  the  bedside,  and 
changed  as  often  as  required.  If  dry  cold  is  to  be  used,  a 
small  rubber  ice-bag  filled  with  chopped  ice,  and  placed 
"within  the  folds  of  a  clean  towel  so  that  at  least  one  thickness 
of  the  towel  comes  between  the  ice-bag  and  the  eye,  is  laid 
upon  the  eye  and  retained  in  position  by  pinning  the  ends  of 
the  towel  behind  the  head,  or  to  the  pillow.      This  form  of 


CLEANSING  THE  EYE. 


45 


cold  application  can  be  used  in  cases  of  conjunctival  inflam- 
mation for  several  hours  at  a  time  with  benefit  and  comfort. 

Hot  applications  may  be  used  dry,  by  means  of  hot  flannels, 
bags  of  hot  bran  or  hot  salt,  as  in  the  ciliary  neuralgia  of 
iritis,  or  flannels  wrung  out  of  hot  water,  compresses  wet  in  a. 
warm  decoction  of  chamomile  flowers,  calendula,  or  hops,  and 
poultices  of  pulverized  slippery-elm  bark,  or  flaxseed,  as  in 
suppurative  cases  of  the  lids,  orbit,  or  cornea.  Moist  heat 
must  not  be  applied  continuously  for  any  length  of  time  as 
oedema  and  relaxation  of  the  tissues  result,  and  ulceration  or 
slow  recovery  follows.  Eye  douches  are  used  in  some  chronic- 
cases,  a  stream  of  water  being  directed  against  the  closed  eye- 
lid from  a  fountain  syringe,  the  temperature  of  the  water 
being  that  which  is  most  grateful  to  the  eye. 

CLEANSING  THE  EYE. 


For  removing  dis^iarges  from  the  eye= 
small  bits  of  old  muslin,  linen,  camel's- 
hair  brushes  or  absorbent  cotton  or  the 
sub-palpebral  syringe  of  Dr.  Liebold 
(Fig.  19)  may  be  used.  With  whatever 
method  employed,  the  end  is  better  at- 
tained by  the  use  of  some  disinfectant 
lotion.  Chlorine  water,  which  may  be 
diluted  one-half  or  one-third,  or  used  in 
full  strength,  as  the  irritation  after  its. 
use  is  very  slight,  forms  one  of  the 
best   disinfecting  lotions.     Boracic   acid, 

grs,  viii  ad  f3i,  is  more  frequently  at  hand  and  gives  good 

satisfaction. 


e.TI£MANN  8<C0 
FIG.  19. 


MYDRIATICS  AND  MYOTICS. 


Certain  substances  which  possess  the  power  of  dilating  or 
contracting  the  pupil  when  applied  directly  to  the  eye  have 
received  the  name  of  mydriatics  and  myotics.  Among  the 
mydriatics  are  sulphate  of  atropia,  hydrobromate  of  homatro- 


4(5  DISEASES  AND  INJURIES  OF  THE  EYE. 

pine,  belladonna,  hyoscyamine,  daturine,  gelsemium,  and  the 
sulphate  of  duboisia.  Until  a  recent  period  atropia  sulphate 
has  been  considered  the  most  useful  and  important  of  the 
mydriatics,  but  homatropine  and  duboisia  are  now  filling 
needed  places  in  the  armamentarium  of  the  oculist.  They  are 
all  poisonous  and  exert  their  toxic  effects  on  passing  through 
the  tear  passages  to  the  throat  and  there  becoming  absorbed. 
For  general  purposes  where  the  dilation  of  the  pupil  is 
■desired,  the  solution  of  sulphate  of  atropia,  grs.  iv.  ad  f^i  of 
wa^er,  will  furnish  the  best  mydriatic.  In  its  application  a 
drop  is  to  be  placed  in  the  lower  conjunctival  fold  with  a 
medicine-dropper  (Fig.  20),  and  in  ordinary  cases 
after  twenty  minutes  or  half  an  hour  the  pupil  will 
be  found  to  be  fully  dilated.  The  paralysis  of  the 
ciliary  muscle  follows  in  from  one  and  a  half  to  two 
houi's,  lasts  a  day,  but  does  not  entirely  disappear  for 
one  or  two^weeks.  It  also  acts  as  an  anodyne  in 
relieving  the  reflex  irritation  from  the  nerves  of 
sensation  of  the  cornea  and  iris.  Where  care  is  not 
used  in  its  frequent  application,  the  symptoms  of 
atropine  poisoning  may  occur.  These  are  usually,  first 
dryness  of  the  throat,  then  flushing  of  the  face, 
headache,  palpitation  of  the  heart,  acute  mania,  deli- 
rium, retention  of  urine,  urging  to  urinate,  nausea 
and  prostration.  On  the  occasion  of  any  of  these 
symptoms  the  use  of  the  atropine  should  be  stopped 
FIG.  20.  and  draughts  of  black  coffee  administered  until  vomit- 
ing takes  place,  or  morphia  or  brandy  may  be  given  if  the 
prostration  is  great.  If  the  atropine  is  dropped  into  the  eye 
near  the  outer  canthus  and  the  head  held  to  that  side  for  a 
few  moments  or  pressure  made  over  the  lachrymal  sac  the 
poisonous  effects  are  not  likely  to  prove  troublesome.  In 
young  children  a  solution  of  ^  gr,  to  the  f  3  should  be  used. 
In  rare  cases  atropine  produces  irritation  or  inflammation  of 
the  conjunctiva.  In  these  cases  sulphate  of  duboisia,  grs.  iv 
ad  f si,  will  prove  l^seful.  It  has  the  same  effect  upon  the  eye 
as  the  atropine,  the  full  effect  being  obtained  in  an  hour,  but 


INSTRUMENTS.  47 

lasts  only  about  six  hours  and  its  influence  disappears  in  about 
seven  days.  Its  toxic  effects  appear  more  rapidly  and  are 
more  alarming,  and  are  usually  vertigo,  unconsciousness,  or 
extreme  prostration.  Homatropine  hydrobromate,  grs.  xvi  ad 
f'i,  one  to  three  drops,  in  the  eye  dilates  the  pupil  and 
paralyzes  accommodation  in  an  hour,  but  the  effect  passes 
off  in  24  or  36  hours.  The  other  mydriatics  mentioned  above 
are  rarely  if  ever  used  in  ophthalmic  practice  now. 

Of  the  myotics  we  have  the  hydrobromcde  of  pilocarpine 
and  the  sulphate  of  eserine.  The  former  is  mild  in  its 
action  and  has  been  recommended  as  a  local  tonic  for  the 
ciliary  muscle.  In  a  solution  of  gr.  iv  ad  f3i,  it  produces 
contraction  of  the  pupils  and  spasm  of  the  ciliary  muscle, 
the  effect  passing  off  in  3(3  to  48  hours.  The  sulphate  of 
eserine  is  a  more  powerful  myotic,  a  solution  of  grs.  iv  ad 
£31  causing  the  utmost  contraction  of  the  pupil,  and  spasm  of 
the  accommodation  with  pain,  in  half  an  hour  to  an  hour; 
its  effects  are  transient  and  disappear  in  a  few  hours.  It 
is  used  to  draw  the  iris  away  from  a  peripheral  ulceration 
or  wound  of  the  cornea,  to  counteract  the  paralysis  of  the  iris 
or  ciliary  muscle  and  in  some  cases  of  glaucoma  to  draw  the 
periphery  of  the  iris  away  from  the  angle  of  the'  iris,  thus 
lessening  the  pressure  upon  the  canal  of  Schlemm. 

INSTRUMENTS. 

In  all  operative  procedures  upon  tlie  eyeball,  the  lids  must  be 
held  apart  by  the  fingers  of  a  competent  assistant,  or  Desmarres's 


^1  » 


lid  elevators  (Fig.    21)   employed,   or  a  speculum,    designed 
for  the  purpose,  used.    A  variety  of  the  latter  instruments  have 


48 


DISEASES  AND  INJURIES  OF  THE  EYE. 


been  devised  and  are  in  use  by  different  operators.  The 
requisites  of  a  proper  speculum  are  that  the  lids  should  be  as 
widely  separated  by  it  as  the  palpebral  fissure  will  allow,  it 

should  not  cause 
any  pressure  upon 
the  eyeball,  and 
should  not  project 
from  the  lids  or 
temple  so  as  to  in- 
terfere with  the 
manipulations  of 
the  surgeon.  There 


e.  TiCMANNS,  C  0.  N.  K 


FIG.  22. 


is  no  single  speculum  which 

is  well  suited  for  all  purposes. 

An  ordinary  wire  speculum 

will  answer  for  many  cases. 

That  of  Noyes  (Fig.  22)  is  as 

well  adapted  as  any  form  of 

spring  speculum  for  common 

use,  but  is  often  impracticable  when  the   eyes   are  deep  set. 

That  of  Liebold   (Fig.   23)   possesses  admirable  features,  as 

when  properly  made  the  body  rests  on  the  temple  and  conforms 

itself  to  the  action  of  the  face.     It  is  out  of  the  way  of  the 

operator.     There  is  no  spring  action,  the  limbs  being  governed 

by  a  slide  to  which  a  small  thumb-screw  is  affixed.     "With  the 


spring  speculums  it  has  happened  to  all  operators,  during  the 
removal  of  the  speculum  after  an  operation,  that  on  turning 
the  instrument  slightly  it  has  slipped  from  the  fingers  and 
perhaps  struck  the  eyeball.  This  accident  might  prove  serious 
after  an  operation  for  cataract,  iridectomy,  etc.,  and  is  avoided 
by  the  use  of  Liebold' s  speculum.  The  speculum  is  readily 
introduced  by  slightly  lifting  the  upper  lid  and  inserting  the 


INSTRUMENTS.  49 

upper  limb  of  the  speculum  and  then  the  lower  lid  is  retracted 
sufficiently  to  allow  the  lower  portion  of  the  instrument  to  rest 
in  the  lower  conjunctival  sac. 

For  steadying  the  eyeball  a  fixation  forceps  (Fig.  24)  is  used, 
and  this  may  be  made  with  or  without  a  spring  catch.  It 
should  be  handled  so  as  to  simply  turn  the  eye  by  slight  push- 
ing and  not  drag  it  The  application  of  the  forceps  becomes 
painful  and  if  not  carefully  manipulated  it  will  tear  the  con- 


junctiva. The  Beers  knife  (Fig.  25)  will  be  found  a  very  useful 
form  of  scalpel  for  operations  about  the  eye,  the  blade  being 
very  thin,  well  pointed,  and  yet  sufficiently  firm  for  all  purposes. 
The  great  variety  of  other  instruments  are  specially  designed 
for  particular  purposes  and  will  be  considered  under  the 
descriptions  of  the  different  operations. 


CHAPTER     IV. 
"WOUNDS  AND  INJURIES  OF  THE  EYE. 

The  proper  management  of  traumatic  injuries  of  the  eye  is 
of  the  utmost  importance,  as  the  resulting  condition  of  the  eye 
depends  very  much  upon  the  treatment  to  which  it  is  subjected 
immediately  after  the  injury.  The  full  extent  of  the  injury 
should  be  ascertained,  and  frequently  it  will  be  necessary  to 
etherize  the  patient,  particularly  if  a  child,  to  gain  a  complete 
inspection  of  the  eye.  Where  practicable,  the  vision  should 
be  tested  and  noted,  as  a  direct  examination  of  the  eye  fre- 
quently has  a  legal  aspect  as  well  as  a  surgical  one.  Having 
determined  the  parts  injured  and  the  extent  of  the  lesion,  and 
decided  upon  the  treatment  necessary,  give  the  eye  perfect  rest 
and  refrain  from  frequent  examination,  which  may  retard  the 
process  of  repair. 

INJTJEIES  OF  THE  ORBIT. 

The  orbit  is  often  the  seat  of  punctured  and  gunshot  wounds 
which  may  or  may  not  directly  implicate  the  eyeball.  Blows 
directed  upon  the  margin  of  the  orbit  may  cause  simply  a  con- 
gestion of  the  soft  parts  with  ecchymosis  of  the  lids,  or 
produce  a  fracture  of  one  of  the  orbital  walls.  The  presence  of 
effused  blood  beneath  the  conjunctiva  of  the  bulb,  within  a  few 
hours  or  just  following  the  injury,  is  an  indication  of  rupture 
of  the  blood-vessels  of  the  orbit.  A  careful  ophthalmoscopic 
examination  should  be  made,  as  serious  changes  may  result  at 
the  same  time  internally  or  behind   the  eye.     Oftentimes    a 


INJURIES  OF  THE  LIDS. 


51 


fracture  of  tlie  orbit  is  overlooked  in  other  serious  injuries  of 
the  head  and  is  followed  by  loss  of  sight  in  one  or  both  eyes 
without  much  change  in  the  fundus.  Rest,  cold  applications, 
and  arnica  locally  and  internally,  are  usually  sufficient,  the 
blood  being  absorbed  in  a  few  days.  Punctured  or  gunshot 
wounds  of  the  orbit  demand  a  thorough  search  for  foreign 
bodies  by  means  of  the  little  finger  or  probe  and  their  immedi- 
ate removal,  when  found.  If  the  entrance  wound  is  not 
sufficiently  large  to  permit  the  removal  of  the  imbedded  object, 
it  must  be  further  enlarged.  In  cases  where  small  shot,  as 
bird  shot,  are  projected  into  the  tissues  of  the  orbit,  those  near 
the  surface  should  be  removed,  but  deep  incisions  and  probings 
in  the  structures  of  the  orbit  are  not  advisable,  as  these  foreign 
bodies  if  left  to  themselves  frequently  become  encysted,  or 
come  to  the  surface  after  a  time.  The  direction  of  punctured 
and  gunshot  wounds,  demands  consideration  and  affects  the 
prognosis  of  this  class  of  injuries,  for,  if  the  roof  is  implicated, 
hemorrhage,  inflammation  and  abscess  of  the  brain  may  result. 
If  the  floor  of  the  orbit  has  been  fractured  or  punctured,  blood 
from  the  nose  is  often  symptomatic,  and  besides  the  opening 
of  the  antrum,  injury  to  the  infra-orbital  nerve  may  result. 
In  the  treatment  of  these  injuries  of  the  orbit  all  foreign 
bodies,  fragments  of  bone,  etc.,  are  to  be  removed,  the  parts 
thoroughly  cleansed,  and  cold  compresses  applied,  with  rest 
and  the  maintainance  of  a  free  opening  for  discharges.  If 
orbital  cellulitis  supervenes  and  abscess  forms  deep  in  the 
orbit,  an  incision  to  allow  free  discharge  is  imperative,  and  if 
cerebral  complications  ensue,  it  may  be  necessary  to  remove 
the  eyeball. 

INJURIES  OF  THE  LIDS. 

Wounds  of  the  lids,  however  extensive,  must  be  thoroughly 
cleansed  with  warm  water,  all  portions  of  clothing,  hair,  dirt, 
etc.,  removed,  the  edges  of  the  wound  well  brought  together 
and  united  with  as  many  fine  sutures  as  may  be  necessary  to 
insure  a  full  adaptation  of  the  lacerated  tissues,  when  primary 


52  DISEASES  AND  INJURIES  OF  THE  EYE. 

union  will  almost  always  take  place.  Generally  the  applica- 
tion of  dry  dressings  is  all  that  is  necessary.  If,  however,  the 
wound  becomes  painful,  cold  compresses  of  calendula  water 
and  the  use  of  Aconite,  Arnica,  or  Calendula  internally  are 
indicated. 

The  ecchymosis  of  the  lids  or  "  black  eye  "  from  contusion 
requires  the  use  of  Arnica  externally  and  Hamamelis  inter- 
nally. Incised  wounds  of  the  lids  may  cause  ptosis  from  the 
division  of  the  levator  palpebraB,  or  if  in  the  supra-orbital 
region,  loss  of  sight  as  well.  Burns  of  the  lids  may  cause 
changes  in  the  position  by  the  resulting  cicatrices  and  requii'e 
the  same  treatment  necessary  for  burns  of  the  cuticle  else- 
where. Superficial  burns  of  the  eyelids  become  more  impor- 
tant than  similar  burns  on  other  portions  of  the  skin.  If  the 
lids  are  severely  burned  or  scalded,  lint  soaked  in  a  solution 
of  lime  water  and  linseed  oil,  or  a  thick  paste  of  bicarbonate 
of  soda  should  be  applied  to  the  parts.  The  latter  I  have 
found  relieves  pain  more  rapidly  than  any  other  dressing. 
Occasionally  Cantharis  will  do  good  in  lessening  the  tendency 
to  suppuration  which  follows  in  these  cases.  Where  cicatrices 
form,  plastic  skin  operations  will  have  to  be  considered  later. 
Gunpowder  grains  imbedded  in  the  tissue  of  the  lid  require 
the  most  painstaking  effort  at  their  thorough  removal. 

INJURIES  OF  THE  LACHRYMAL  APPARATUS. 

Foreign  bodies  sometimes  find  their  way  into  the  lachrymal 
conduits,  as  lashes,  hairs,  bits  of  straw,  etc.,  and  should  be 
looked  for  in  the  puncta  when  the  irritation  is  not  found  else- 
where. Where  these  ducts  have  been  divided  by  ivounds,  the 
repair  cannot  be  expected  to  restore  the  integrity  of  the  parts, 
and  future  operations  may  be  necessary  to  open  them. 

INJURIES  OF  THE  CONJUNCTIVA 

The  injuries  sustained  by  the  conjunctiva  are  numerous, 
and  in  extent  usually  greater  than  those  of  the  eyeball.  They 
may  consist  of  incised  wounds,  burns,  or  foreign  bodies  upon 


INJURIES  OF  THE  CONJUNCTIVA.  53 

or  in  its  tissue.  Foreign  bodies  impinging  upon  the  surface 
of  the  conjunctiva  are  usually  washed  off  by  the  profuse  secre- 
tion of  tears  caused  by  the  irritation,  unless  the  efforts  of  the 
patient  to  remove  them  by  rubbing,  imbed  them  in  the  tissue. 
If  a  small  fly,  or  other  minute  insect,  or  foreign  body  becomes 
lodged  in  the  eye,  it  is  usually  found  near  the  palpebral 
margin  of  the  upper  lid,  each  movement  of  the  lid  causing 
severe  pain  as  the  object  scratches  upon  the  cornea.  Upon 
eversion  of  the  upper  lid  it  is  removed  without  diJEhculty.  If 
it  remains  for  any  length  of  time,  or  an  eye-stone  is  inserted, 
conjunctivitis  results,  but  rapidly  subsides  upon  the  removal 
of  the  foreign  body  or  eye-stone.  Gunpowder  grains  become 
imbedded  in  the  conjunctiva  from  explosions,  and  necessitate 
the  removal  of  all  free  grains,  and  the  excision  of  minute 
portions  of  the  conjunctiva  together  with  those  grains  which 
Ijecome  imbedded  in  its  tissue.  This  may  be  done  immediately 
after  the  injury  has  been  received,  or,  if  the  reaction  is  too 
excessive  from  the  injury  to  other  parts,  their  removal  may  be 
left  until  some  future  time,  when  the  eye  has  recovered  from 
the  immediate  effects  of  the  injury. 

Incised  wounds  or  lacerations  of  the  conjunctiva  require 
little,  if  any,  treatment,  beyond  the  use  of  cold  compresses  and 
enforced  quiet  of  the  eye  by  bandaging,  as  they  heal  very 
readily.  Burns  of  the  eye  from  lime,  mortar,  molten  metals, 
ammonia,  sulphuric  and  nitric  acids,  or  other  caustic  substances 
are  very  common,  affecting  the  conjunctiva,  and  requiring  the 
installation  of  such  oily  substances  as  cream,  vaseline,  sweet 
oil,  etc.,  Avliich  may  be  at  hand.  In  the  case  of  lime  or  mor- 
tar, all  particles  must  be  carefully  picked  from  the  conjunctival 
fold  by  forceps  or  a  spud,  and  syringing  may  be  necessary  to 
remove  more  minute  bits.  Etherize  the  patient,  if  necessary  to 
do  it  perfectly.  After  all  have  been  removed,  instil  castor 
oil  or  vaseline  between  the  lids  and  keep  the  eye  at  rest. 
Burns  from  melted  metal  are  usually  less  deep  than  those  of 
lime,  as  the  metal  solidifies  rapidly  and  is  more  easily  removed. 
Eschars  are  produced  from  acetic,  sulphuric,  or  nitric  acids,  or 
concentrated  lye ;  and  after  the  parts  have  been  well  washed 


54 


DISEASES  AND  INJURIES  OF  THE  EYE. 


"with  water  the  reaction  must  be  waited  for.  The  use  of  alka- 
line solutions  in  the  case  of  acids,  or  acid  solutions  in  the  case 
of  the  introduction  of  alkalies  into  the  eye  is  misleading,  as 
the  danger  is  usually  done  before  the  antidote  in  either  case 
can  be  applied,  and  the  superficial  injuries  sustained  by  their 
dilution  in  large  quantities  of  water,  are  very  slight.  The 
danger  in  burns  of  the  conjunctiva,  from  whatever  cause,  is 
from  adhesion  of  the  granulating  surface  after  the  eschar  has 
been  discharged,  and  this  union  of  the  conjunctiva  of  the  lids 
and  globe  cannot  be  prevented  any  further  than  by  the  con- 
stant instillation  of  oil,  and  perhaps  the  frequent  breaking  up 
of  the  cicatricial  bands  by  the  probe.  The  adhesions  which 
form  from  the  contracting  cicatrix  requires  future  operation. 
If  these  burns  have  not  involved  the  cornea,  there  is  no 
necessary  impairment  of  vision,  unless  the  adhesions  are 
sufficient  to  impede  the  motion  of  the  eyeball  so  that  its  move- 
ment is  not  associated  with  its  fellow. 

INJUEIES  OF  THE  COENEA, 

Foreign  bodies,  particles  of  iron,  cinders,  seed  husks,  etc., 
become  imbedded  in  the  cornea,  and  may  present  only  slight, 
if  any,  irritation  for  several  days,  after  which  time  inflamma- 
tion or  pain  occur.     In  the  removal  of  these  foreign  bodies  if 


FIG.  27. 


the  eye  cannot  be  controlled,  an  anaesthetic  must  be  used. 
Under  ordinary  circumstances,  the  patient  may  be  seated  upon 
a  chair  of  ordinary  height  before  a  good  light  with  his  head 
resting  upon  the  chest  of  the  surgeon,  who  stands  behind. 
The  operator  fixes  the  eyeball  with  the  thumb  and  fore-finger 
of  the  left  hand,  and  making  slight  pressure  upon  the  margin 
of  the  orbit,  the  eyeball  is  well  controlled.     In  a  majority  of 


INJURIES  OF  THE  CORNEA.  55 

cases,  with  a  sharp  gouge  (Fig.  2G)  or  spud  (Fig.  27)  in  the 
other  hand,  the  foreign  body  will  be  raised  and  removed  without 
difficulty.  If,  however,  the  hand  is  not  steady,  the  other 
portions  of  the  cornea  are  touched  and  the  pain  will  be  severe. 
If  a  foreign  body  extends  into  the  deeper  layers  of  the  cornea, 
or  into  the  anterior  chamber  it  will  become  necessary  to 
enter  a  narrow  cataract  knife  through  the  anterior  chamber 
and  by  cutting  outwards,  remove  it,  or,  using  the  knife  tip  for 
a  rest,  the  foreign  body  may  then  be  seized  by  a  pair  of 
forceps  and  withdrawn.  The  after-treatmont  of  such  cases  is, 
as  a  rule,  very  simple.  The  instillation  of  a  drop  of  atropine 
and  the  application  of  a  bandage,  even  in  those  cases  where 
the  cornea  has  been  incised  are,  oftentimes,  all  sufficient.  In 
cases  of  foreign  bodies  simply  impinging  upon  the  cornea,  the 
use  of  a  lotion  of  aconite  tincture  and  water  relieves  the  pain 
from  exposure  of  the  nerve  filaments  in  the  cornea,  and 
hastens  repair.  If  suppuration  has  commenced  about  the 
point  of  entrance  of  the  foreign  body,  atropine  two  or  three 
times  a  day  will  generally  relieve  the  pain,  while  the  use  of 
Aconite,  Hepar  sulphur,  Silicia,  or  Mercury,  as  the  case  may 
indicate,  will  hasten  the  reparative  process.  Scars  that  may 
be  left  will  injure  vision  according  to  their  position  and  extent, 
by  lessening  the  transparency  of  the  cornea.  Abrasions  of  the 
surface  from  the  scratch  of  the  finger-nail  of  a  child  or  a  twig, 
require  usually  only  a  bandage  and  rest  for  the  eyes  during 
forty-eight  hours,  until  the  epithelial  layer  has  again  been 
re-produced.  If  occurring  in  nursing  women,  or  where  there 
is  a  low  condition  of  the  system,  suppuration  of  the  cornea 
and  destruction  of  vision  may  result.  Contusions  of  the 
cornea  from  direct  blows  upon  the  eyeball  are  rare,  but 
usually  cause  suppuration,  keratitis,  or  abscess,  and  become 
one  of  the  most  dangerous  affections  of  the  eye.  Such  results 
follow  more  frequently  in  aged  persons  than  in  the  young,  and 
arise  from  small  objects  striking  the  cornea  directly,  and  as 
all  abscesses  or  suppurations  of  the  cornea  are  followed  by 
some  opacity,  the  vision  thereby  becomes  defective.  In  the 
treatment,  cold  applications,  and  Arnica  are  the  first  indicc- 


56  DISEASES  AND  INJURIES  OF  THE  LYE. 

tions.  If  suppuration  becomes  established,  the  temperature 
of  the  applications  must  be  changed,  and  thin  compresses  wet 
with  a  hot  infusion  of  calendula  flowers  applied  for  half  an 
hour  at  a  time  several  times  a  day,  and  the  administration  of 
Hepar  or  Silicia  may  assist  in  impro-\jing  the  condition.  The 
presence  of  pus  in  the  anterior  chamber  may  necessitate  para- 
centesis to  draw  off  the  aqueous  and  thus  lessen  the  tension. 
The  cornea  is  frequently  the  seat  of  incised  wounds  resulting 
from  explosions,  direct  cuts  or  thrusts  from  various  objects. 
If  the  wound  is  merely  an  incised  one,  it  may  be  extensive 
without  necessarily  destroying  the  vision;  however,  if  the 
wound  is  at  all  extensive  there  is  loss  of  the  aqueous 
humor,  and  frequently  prolapse  of  the  iris  into  the  wound; 
where  there  is  no  hernia  of  the  latter  present,  the  eyelids 
should  be  closed,  after  the  instillation  of  a  drop  of  atropine, 
and  a  bandage  applied,  the  patient  being  confined  to  the  bed 
and  every  effort  made  to  give  the  organ  absolute  rest,  and 
thus  facilitate  the  union  which  takes  place  in  a  few  days.  If 
there  is  prolapse  of  the  iris,  it  is  not  advisable  to  attempt  to 
return  it  to  the  anterior  chamber  by  any  manipulation,  as  the 
pressing  of  these  delicate  parts  results  in  iritis  and  further 
complicates  the  case.  The  projecting  portion  of  the  iris  may 
be  cut  off  close  to  the  cornea  with  a  pair  of  curved  iris  scissors. 
If  the  iris  is  caught  in  the  wound  during  the  progress  of 
healing  and  bulges  by  reason  of  pressure  from  the  aqueous 
behind  it,  it  should  be  punctured  with  a  cataract  knife  until 
by  gradual  contraction  it  heals  without  projection;  sometimes 
the  iris  tissue  degenerates  into  a  cystoid  condition  which  will 
require  opening  with  a  cataract  knife,  and  close  dissection 
with  fine  scissors  of  the  tissue  down  to  the  cornea,  the  appli- 
cation of  a  bandage,  and  maintainance  of  rest  until  the  wound 
again  heals.  Small  incised  wounds  of  the  cornea,  if  no  other 
portions  of  the  eye  are  injured,  are  almost  harmless,  as  they 
heal  very  rapidly.  Wounds  of  this  portion  of  the  eye  are 
more  frequently  complicated  by  contusion,  hemorrhage, 
prolapse  of  the  iris,  wounds  of  the  lens  or  deeper  structures, 
and  hence  become  much  more  grave. 


INJURIES  OF  THE  SCLERA  AND  IRIS.  57 

INJURIES  OF  THE  SCLERA. 

Wounds  lying  in  the  sclera  are,  as  a  rule,  much  more 
dangerous  to  the  integrity  of  the  eye  than  corresponding  ones 
of  the  cornea.  The  unyielding  nature  of  the  fibrous  tissue  of 
the  sclera  and  the  prolapse  of  the  vitreous  prevent  the  edges 
of  the  wound  from  coming  into  close  apposition,  and  hence  it 
heals  with  difficulty.  Fine  sutures  may  be  introduced  and  the 
wound  brought  together,  with  very  excellent  results  in  some 
cases.  Rupiure  of  the  sclera  may  result  from  direct  compres- 
sion of  the  eyeball,  as  in  a  blow  from  a  closed  fist,  blunt 
instrument  or  a  fall.  The  seat  of  rupture  is  usually  at  the 
upper  and  inner  portion  near  the  junction  of  the  cornea,  or 
between  the  cornea  and  insertion  of  the  recti  muscles.  If 
sufficient  to  occasion  a  rupture  of  the  sclera  it  will  cause 
severe  injuries  to  the  other  structures  of  the  eyeball,  the  lens 
frequently  being  driven  out  through  the  opening,  the  vitreous 
may  follow,  and  the  eyeball  collapse.  Again,  detachment  of 
the  choroid  or  retina  may  accompany  the  injury  from  rupture 
of  the  blood-vessels  of  the  choroid.  Wounds  of  the  sclera 
"become  dangerous  from  the  fact  that  the  ciliary  body,  choroid 
and  retina  may  prolapse  in  the  wound  during  the  process  of 
healing  and  cause  sufficient  irritation  to  set  up  sympathetic 
irido-choroiditis  in  the  other  eye,  and  necessitate  the  removal 
of  the  injured  eyeball.  Hence  the  prognosis  should  be  very 
guarded,  as  often  in  slight  cases  of  detachment  of  the  retina, 
degeneration  of  the  vitreous  and  other  more  remote  changes 
may  result.  In  cases  where  the  lens,  choroid,  or  ciliary  body 
are  prolapsed  in  the  wound  and  the  eyeball  collapsed  it  is 
better  to  remove  the  eyeball  at  once  as  it  has  already  become 
sightless.  In  some  cases  of  rupture  of  the  sclera,  the  wound 
may  lie  towards  the  posterior  portion  and  thus  be  hidden  from 
inspection.  The  lessened  tension,  which  is  always  present  in 
ruptures  of  the  sclera,  will  cause  us  to  suspect  it  in  this  case. 

INJUEIES  OF  THE  IRIS. 

Wounds  of  the  iris  are  usually  accompanied  by  injuries  to 
other   structures.     The  prolapse  in  cases  of  wounds   of  the 


58 


DISEASES  AND  INJURIES  OF  THE  EYE. 


cornea  has  already  been  considered.  Incised  wounds  of  the 
iris  alone  are  extremely  rare.  When  occurring  they  cause  an 
effusion  of  blood  into  the  anterior  chamber,  which  obscures 
the  iris.  This  blood  is  usually  absorbed  in  thirty-six  hours, 
when  a  cut  will  be  found  at  the  place  of  injury,  as  the  wound 
does  not  unite,  owing  to  the  absence  of  inflammatory  action  in 
this  case  and  the  separation  of  the  parts.  Eest  and  quiet  of 
the  eye  are  necessary  until  the  blood  has  been  absorbed,  when 
the  extent  of  the  injury  can  be  ascertained  and  the  prognosis 
made  accordingly.  Detachment  of  the  iris  from  the  ciliary 
body,  in  whole  or  in  part,  may  occur  from  injuries  affecting 
only  the  iris  or  also  involving  the  cornea.  Blows  received 
upon  the  eye  may  cause  a  separation  of  the  iris  from  a  portion 
of  the  ciliary  body ;  after  the  effused  blood  has  been  absorbed, 
a  second  pupil,  as  in  Fig.  28,  will  be  observed,  but  that  portion 

of  the  pupil  will  be  irregular,  and 
the  iris,  from  laceration  of  its  nerves 
and  muscles,  will  not  respond  to  the 
stimulus  of  light ;  the  vision  will  be 
somewhat  impaired  by  the  increased 
amount  of  light  which  is  thus  ad- 
mitted to  the  eye  causing  confusion 
Ke-attachment  of  the  iris  is  not 
possible,  but  rest  should  be  enjoined  until  the  eye  has 
recovered  from  the  effects  of  the  blow,  or  of  deeper  injuries, 
such  as  detachment  of  the  retina,  which  may  complicate  the 
case.  A  complete  detachment  of  the  whole  of  the  iris  may 
occur,  as  it  has  in  two  cases  which  have  come  under  my 
notice :  the  first,  where  the  iris  was  injured  by  a  thrust  from 
a  wad-remover,  which  caused  a  lacerated  wound  of  the  cornea 
and  removed  over  two  thirds  of  the  iris,  the  remaining  portion 
being  prolapsed  in  the  wound.  In  the  second  case  the  cornea 
was  incised  by  a  cut  from  a  broken  bottle,  and  the  iris  pro- 
lapsed, and  was  removed  entire  by  the  unskillful  attempt  to 
remove  the  prolapse.  Foreign  bodies  which  pass  through  the 
anterior  chamber  often  lodge  upon  the  iris,  where  they 
rarely  become  encysted,  though  I  have  seen  one  case  in  which 


of 


na.28. 
the    retinal 


image. 


INJURIES  OF  THE  LENS.  59 

a  bit  of  wood  remained  encysted  in  tlie  iris  for  several  years 
without  causing  trouble.  Foreign  bodies  in  this  region  are 
readily  discovered  by  focal  or  oblique  illumination.  If  a 
foreign  body  has  lodged  upon  the  iris,  an  opening  in  the 
cornea  should  be  made  with  an  iridectomy  or  cataract  knife» 
the  iris  forceps  introduced,  and  the  portion  of  the  iris  contain- 
ing the  foreign  body  seized  and  brought  out,  the  iris  thea 
excised,  atropine  solution  introduced,  and  the  eye  bandaged. 
No  delay  in  the  removal  of  foreign  bodies  should  occur  here, 
and  if  the  eye  is  already  inflamed  an  operation  is  still  more 
imperative.  If  the  foreign  body  consists  of  iron  or  steel,  an. 
opening  into  the  anterior  chamber  may  be  made,  when  the 
introduction  of  the  point  of  a  magnet  into  the  wound  may  be 
sufficient  to  attract  the  particle,  and  upon  withdrawal  of  the 
magnet  the  bit  of  iron  or  steel  follows.  All  injuries  of  the 
iris,  whether  from  incised  wounds  or  foreign  bodies,  require 
the  instillation  of  a  solution  of  atropine,  four  grains  to  the 
ounce,  to  dilate  the  iris  ad  maximum  and  retain  it  there  until 
all  symptoms  of  inflammation  have  disappeared.  The  dilata- 
tion of  the  pupil  will  also  enable  us  to  form  a  prognosis,  as  a 
wound  of  the  lens  at  a  part  covered  by  the  iris  in  its  undilated 
state  may  thereby  be  revealed,  and  thus  affect  our  prognosis 
and  cause  a  change  in  the  line  of  treatment. 

INJUKIES  OF  THE  LENS. 

Ruptures  of  the  sclera  from  blows  may  cause  at  the  same 
moment  loss  of  the  lens  from  the  eye,  or  if  the  conjunctiva 
remains  intact,  the  lens  becomes  dislocated  beneath  it.  The 
sac  of  conjunctiva  thus  formed  may  also  contain  blood, 
vitreous  or  prolapse  of  the  iris.  The  tension  of  the  eyeball 
is  lessened  and  it  feels  soft  under  the  pressure  of  the  fingers. 
The  lens  usually  gives  shape  to  the  sac  and  renders  diagnosis- 
more  easy.  If  the  anterior  chamber  is  clear,  the  loss  of 
support  of  the  iris  from  the  absence  of  the  lens  gives  it  a 
tremulous  appearance,  and  if  the  iris  is  prolapsed  distortion 
of   the  pupil    follows.       The  anterior    chamber,  however,    ia 


^0  DISEASES  AND  INJURIES  OF  THE  EYE. 

frequently  filled  with  blood  and  obscures  the  condition  of  the 
interior.  The  prognosis  is  usually  unfavorable ;  the  lens  may 
be  removed  by  an  incision  from  the  conjunctival  side,  or 
allowed  to  become  absorbed  without  removal,  and  if  no  more 
serious  injury  of  the  eyeball  has  been  sustained,  recovery  may 
be  good.  The  treatment  consists  in  placing  the  patient  in 
a  recumbent  position,  and  in  preventing  motion  of  the  balls 
lay  a  bandage,  applying  cold,  and  avoiding  all  muscular  effort 
of  the  face  as  in  chewing,  coughing  or  straining  at  stool.  If 
the  lens  is  only  partially  in  the  wound  and  presses  upon  the 
iris,  it  should  be  removed ;  otherwise  it  is  better  to  delay  the 
removal  of  the  lens  until  the  scleral  wound  is  healed. 
Suppurative  inflammation  of  the  globe  may  be  the  result  of 
an  injury  of  this  kind  and  will  require  the  treatment  to  be 
described  further  on.  Dislocation  of  the  lens  may  be  partial 
or  complete ;  if  forward  into  the  anterior  chamber  it  should  be 
removed  promptly  or  increased  tension  follows,  and  the  pres- 
sure upon  the  iris  existing  for  any  length  of  time  causes 
inflammation  of  its  structure  which  rapidly  extends  to  the 
choroid.  If  the  dislocation  is  backward  into  the  vitreous,  the 
lens  may  be  allowed  to  remain  undisturbed  and  may  become 
encysted  or  absorbed.  Punctured  wounds  of  the  lens,  if  of 
slight  extent,  may  cause  opacity  of  a  small  portion  of  it.  If 
the  capsule  of  the  lens  is  lacerated  to  any  extent  from  this 
cause  iraumcdic  cataract  results.  I  have  seen  Cannabis 
indica  and  Conium  clear  this  up,  where  medication  followed 
immediately  after  the  injury.  The  operation  of  discission  will 
be  demanded  at  some  future  time,  or  if  the  lens  becomes  much 
swollen,  and  extrudes  from  its  capsule  into  the  anterior 
chamber,  from  imbibition  of  the  aqueous  through  its  torn 
capsule,  the  pressure  thus  made  upon  the  iris  may  endanger 
inflammation,  and  the  removal  of  the  whole  lens  in  its  capsule 
may  be  necessary  to  prevent  the  transmission  of  sympathetic 
trouble  to  the  other  eye. 

Foreign  bodies  may  lodge  upon  the  capsule  or  enter  the  lens 
and  thus  produce  an  opacity  of  its  structure,  or  blows  received 
upon  the  eye  may  cause  traumatic  cataract  by  rupture  of  its 


INJURIES  OF  THE  VITREOUS.  61 

capsule  at  tlie  periphery.  Foreign  bodies  in  tlie  lens  rapidly 
produce  a  cataractous  condition  and  occasion  inflammation 
which  may  extend  to  the  iris  and  choroid,  and  thus  cause 
sympathetic  cyclitis  of  tlie  other  eye.  In  all  cases  of  injury 
to  the  lens,  the  iris  should  be  dilated  and  the  eye  kept  at  rest 
by  a  pad  or  bandage,  and  if  inflammatory  symptoms  super- 
vene, it  will  be  necessary  to  etherize  the  patient  and  make  an. 
iridectomy  and  remove  the  lens,  upon  the  occurrence  of  any 
marked  increase  in  the  tension.  The  changes  in  the  trans- 
parency of  the  lens,  in  injury  to  the  eyeball,  may  not  follow 
for  some  days  or  weeks  after  the  accident  has  occurred. 

INJURIES  OF  THE  VITREOUS. 

Among  the  accidents  occurring  to  the  vitreous  humor  after 
concussion  or  punctured  wounds  beyond  the  lens,  is  hemor- 
rhage from  the  ruptured  blood-vessels  of  the  choroid.  The 
vision  is  quantitative,  the  patient  being  able  to  distinguish 
between  light  and  darkness  only.  It  is  important  to  ascertain 
the  extent  of  the  field  of  vision,  to  enable  us  to  determine 
whether  there  has  been  detachment  of  the  retina  or  choroid. 
Owing  to  the  impossibility  of  examination  with  the  ophthal- 
moscope,  we  can  only  determine  this  by  testing  the  patient  in 
a  dark  room  with  a  lamp  or  candle,  which  is  held  four  or  five 
feet  from  him,  and  the  position  of  which  is  changed  so  as  to 
define  the  field  of  vision,  which,  if  found  to  be  good,  indicates 
no  detachment  of  the  retina.  If  the  field  is  very  dim  above 
and  clear  below,  partial  detachment  of  the  retina  is  diagnosed, 
or  if  the  field  is  absent,  total  detachment  may  have  occun-ed. 
Hemorrhage  into  the  vitreous  becomes  absorbed  very  slowly, 
four  to  six  weeks  usually  being  required  to  clear  up  the  blood, 
a  floating  scotoma  resulting  from  the  fibrin  of  the  blood  not. 
infrequently  remaining  behind.  Rest  of  the  eye  and  a  com- 
press bandage  are  indicated,  while  the  internal  administration 
of  Arnica,  Hamamelis,  and  Crotalus  will  hasten  absorption. 

Foreign  bodies,  such  as  fragments  of  percussion  caps,  grains 
of  shot,  small  metallic  chips,  glass  or  stone  find,  after  passing 


62 


DISEASES  AND  INJURIES  OF  THE  EYE. 


through  the  cornea  or  sclera,  a  resting  place  in  the  vitreous 
humor.  These  bodies,  if  very  small,  occasionally  become 
encysted  and  the  eye  escapes  immediate  harm,  but  sooner  or 
later  the  eye  is  lost,  and  there  is  only  the  question  of  imme- 
diate removal  of  the  eye,  or  its  removal  at  some  future  time 
when  the  condition  demands  it.  If  the  foreign  body  is  of 
large  size,  no  time  is  to  be  lost  in  the  enucleation  of  the  eye, 
as  the  danger  of  sympathetic  inflammation  is  very  great.  The 
position  of  bodies  in  the  vitreous  may  be  determined  by  the 
ophthalmoscope,  if  the  media  are  clear  and  they  lie  not  too 
far  forward;  usually,  however,  the  passage  of  foreign  bodies 
through  the  vitreous  sets  up  an  inflammation  of  this  tissue 
and  consequent  opacity.  Frequently  they  pass  through  the 
vitreous,  and  rebounding  lodge  upon  or  in  the  ciliary  body 
where  they  rapidly  excite  destructive  inflammation  and  require 
the  early  removal  of  the  eyeball.  Where  particles  of  iron  or 
steel  enter  the  eyeball,  they  may  be  removed  by  the  aid  of 
Knapp's  foreign-body  hook  (Fig.  29),  or  a  magnet,  the  point 


of  which  is  inserted  through  the  wound  of  the  cclerr.,  if 
present,  or  if  the  position  of  the  chip  can  be  determined  by 
the  ophthalmoscope  an  incision  may  be  made  through  the  sclera 
b)eneath  the  foreign  body,  the  point  of  the  magnet  introduced 
and  the  foreign  body  be  withdrawn  with  it.  It  usually  hap- 
pens that  the  particle  is  caught  in  the  edges  of  the  incision, 
whence  it  must  be  removed  by  a  pair  of  fine  forceps;  in  this 
way  the  eyeball  may  be  retained,  but  the  vision  is  almost 
always  destroyed,  either  by  the  inflammatory  process  which 
follows,  or  from  the  eifusion  of  fluid  beneath  the  retina  at 
the  wound.  If  suppuration  has  begun  about  the  foreign  body 
the  removal,  while  admissible,  is  generally  impossible,  and  the 
eye  must  be  enucleated. 

The  accompanying  cut  (Fig.  30)  shows  Dr.  Gruning's  mag- 
net, which  consists  of  several  magnetized  steel  bars,  fitted  into 


INJURIES  OF  THE  CHOROID  AND  RETINA. 


63 


FIG 


malleable  iron  caps,  and  provided  with  a  projecting 
delicate  point  It  is  capable  of  sustaining  a  weight 
of  15  grammes,  or  225  grains,  and  ■wall  attract  chips 
of  iron  weighing  from  1  to  50  centigrammes  at  a 
distance  of  1  to  5  mm.  in  the  vitreous. 

INJXTKIES  OF  THE  CHOROID. 

The  choroid  may  be  ruptured  by  the  reception 
of  blows  upon  the  eyeball  without  external  injury 
to  the  sclera  or  cornea.  Such  injuries  are  accom- 
panied by  heinorrhage  into  the  interior  of  the  eye- 
ball, followed  by  sudden  and  complete  loss  of  vision, 
or  passing  between  the  choroid  and  sclera  the 
hemorrhage  causes  a  detachment  of  the  former, 
or,  if  occurring  beneath  the  retina,  lifts  up  that 
membrane,  and,  if  excessive,  finds  its  way  into  the 
vitreous.  These  hemorrhages  are  rapidly  absorbed 
under  the  use  of  Arnica,  Hamamelis,  Lachesis  and 
Crotalus  and  rest  for  the  eye,  and  frequently  leave 
no  trace  except  a  displacement  of  the  pigment  layer 
along  the  line  of  rupture,  which  usually  shows 
itself  about  the  posterior  pole  of  the  eye.  Inflam- 
matory changes  in  both  retina  and  choroid  may 
result. 

INJURIES  OF  THE  EETINA. 


Injuries  of  the  retina  usually  co-exist  with  those  of  the 
choroid  and  are  mainly  those  of  detachment  from  blows 
which  cause  effusion  of  serum  or  blood  between  the  choroid 
and  its  tissue,  and  destroy  sight  in  proportion  to  the  amount 
of  tissue  separated.  Its  re-attachment  after  injury  is  rare; 
however,  absolute  rest  in  a  recumbent  position  and  bandaging, 
with  the  administration  of  Arnica  and  Gelsemium  may  accom- 
plish much. 


CHAPTEK     V. 

EKEOKS     OF     KEFEACTION. 

KEFKACTION. 


The  refraction  of  the  eye  is  the  ability  which  its  media 
possess,  when  the  eye  is  in  a  state  of  rest,  to  bring  parallel 
rays  of  light  to  a  focus  upon  the  retina  without  muscular 
effort.  Eays  of  light  coming  from  a  luminous  body  diverge 
in  all  directions  from  it,  but  at  a  distance  of  eighteen  or 
twenty  feet  they  are  practically  parallel,  hence  all  distances 
beyond  this  point  are  considered  inJ&nite,  and  those  within 
twenty  feet  are  called  finite. 

Parallel  rays  of  light  passing  through  a  convex  lens  [A 
Fig.  31)   in  a  direction  parallel  to  its  axis,  are  so  converged 

that  they  are  brought  to 
a  point  behind  the  lens 
[F)  at  a  distance  equal 
to  the  focal  power  of 
the  lens.  This  point  is 
termed  the  principal 
focus  of  the  lens.  The 
focal  power  of  the  lens  depends  upon  the  curvatures  of  its 
surface  and  the  index  of  the  refraction  of  the  material  of 
which  it  is  composed.  Substances  differ  in  their  power  of 
changing  the  direction  of  the  rays  of  light,  and  the  measure  of 
this  power  is  called  the  index  of  refraction.  When  divergent 
rays  of  light  (P  Fig.  32)  fall  upon  a  convex  lens  near  its  axis 


ERRORS  OF  REFRACTION. 


C5 


and  come  from  beyond  the  distance  of  its  principal  focns  (-F) 
they  converge  to  a  point  (P')  beyond  the  focal  distance  of 
the  lens.     The  point  (P)   from  which  the  light  diverges  to 

fall  upon  the  lens, 

and    the   point 

P'  (P')  at  which  the 

rays   are    again 


FIG.  32, 


-iic^^'i^fr----- 


FIG.  33. 


T3nited,  are  termed  conju- 
gate foci. 

When  parallel  rays  of  . 
light  fall  upon  a  concave  ; 
lens  in  a  direction  paral- 
lel to  its  axis,  they  pass 
through  and  diverge  from 
it  as  if  they  came  from  a  point  {F  Fig.  83)  on  the  inner 
side  of  the  lens;  this  point  {F)  is  the  principal  focal  point  of 
the  lens  and  in  concave  lenses  is  a  negative  one.  Where  the 
length  of  the  eye  is  normal,  and  the  eye  is 
in  a  state  of  rest,  the  layer  of  rods  and  cones 
in  the  retina  forms  the  principal  focus  of 
the  cornea  and  crystalline  lens,  which  con- 
stitute the  lens  system  of  the  eye  and  may 
be  considered  as  a  combined  convex  lens. 
The  refractive  power  of  the  eye,  then,  is 
the  ability  which  its  media  have  of  bringing 
parallel  rays  of  light  to  a  focus  upon  the 
percipient  elements  of  the  retina  when  the 
accommodation  is  relaxed.  These  rays  of 
light,  on  being  reflected  from  the  retina, 
pass  out  from  the  eye  in  a  parallel  direction. 
The  focal  distance  of  the  lens  system  of  the 
eye  is  about  f  ^  inch  or  20  mm.  measuring 
from  a  point  in  the  anterior  chamber;  the 
focal  length  of  the  cornea  being  31  mm. 
and  that  of  the  lens  43  mm.  The  length. 
FIG.  34.  of  ^^^  optic  axis,  the  line  {FF'   Fig.  84) 


66  DISEASES  AND  INJURIES  OF  THE  EYE. 

drawa  tlirough  the  center  of  the  cornea  to  a  point  midway 
between  the  macula  lutea  (???)  and  the  optic  nerve  entrance 
(o)  is  24  mm.,  while  the  visual  axis,  the  line  [Vm)  which 
joins  the  point  of  the  object  looked  at  with  the  macula 
lutea,  measured  from  the  cornea,  is  about  23  mm.  These 
two  lines  cross  at  the  nodal  point  (/t)  of  the  dioptric  media 
of  the  eye  and  form  an  angle  which  is  called  the  angle 
alpha  (a)  and  measures  about  5°,  decreasing  when  the  eye- 
ball is  elongated  as  in  myopia,  and  increasing  when  it  is 
shortened  as  in  hypermetropia ;  the  angle  being  determined 
by  the  position  of  the  yellow  spot  in  reference  to  the  axis  of 
the  cornea.  The  nodal  point  [Jc)  is  the  optical  centre  of  the 
eye  and  is  situated  near  the  posterior  surface  of  the  crystal- 
line lens.  The  angle  formed  by  the  crossing  of  the  visual 
rays  at  the  optical  centre  determines  the  size  of  the  image 
formed  on  the  retina.  The  nodal  point  changes  with  the 
effort  of  accommodation.  It  may  be  advanced  or  caused  to 
recede  by  placing  a  convex  or  concave  lens  in  front  of  the  eye, 
when  the  retinal  image  is  also  affected,  being  increased  by  the 
former  and  diminished  by  the  latter. 

EM^IETEOPIA  AND  AMETEOPIA. 

The  eye  is  said  to  be  emmetropic  when  its  refractive  power 
is  such  as  to  bring  parallel  rays  of  light  to  a  focus  upon  the 
retina  when  the  accommodation  is  in  a  state  of  full  relaxation, 
and  also  when  it  possesses  the  faculty  of  increasing  this  refrac- 
tion by  the  exercise  of  the  accommodation  to  such  a  degree  as 
to  form  well-defined  images  from  divergent  rays.  The  vision 
of  such  an  eye  is  perfect  for  distance,  and  the  use  of  even  a 
weak  concave  or  convex  glass  lessens  the  distinctness  of  the 
image.  An  eye  to  be  emmeiropic,  or  normal,  must  have  an 
antero-posterior  diameter  of  about  twenty-three  mm. ;  if  the 
axis  is  longer  or  shorter  than  this  the  eye  becomes  ameiropic, 
and  parallel  rays,  with  the  accommodation  at  rest,  are  not 
brought  to  a  focus  upon  the  retina,  but  either  in  front  or  behind 
it.     In  practice  we  do  not  usually  employ  atropine  or  other 


SPECTACLES.  .  67 

mydriatics  to  paralyze  tlie  accommodation  in  determining  the 
refraction,  hence  we  must  make  allowance  for  this.  An  eye 
which  is  emmetropic  has  the  vision  made  worse  by  the  use  of  a 
convex  glass,  and  the  vision  is  not  further  improved  by  the 
use  of  a  concave  glass.  If  a  convex  glass  placed  before  the 
•eye  does  not  disturb  the  vision  or  actually  improves  it,  then 
hypermetropia  is  present;  if  it  is  improved  by  a  concave 
glass  then   myopia  becomes   apparent.      In   Fig.    35,  which 

shows  the  rela- 

€:;-v.^  tive    length    of 

n\  \        the   hyperme- 
-^J^-^^ tropic,  emme- 
!\i  j\      tropic  and  my- 
^/         opic    eye,    the 

J)         SCB  M    retina   of  the 
no.  3?!.  11- 

hypermetropic 

S  is  in  advance  of  that  of  the  emmetropic  E,  while  that 
of  the  myopic  eye  M  lies  behind.  Parallel  rays  from  B  B 
are  brought  to  a  focus  in  the  hypermetropic  eye  at  E,  or 
l^ehind  its  retina  H,  unless  the  accommodation  is  exercised, 
"while  in  the  normal  eye  the  focus  is  at  E  and  in  the  myopic 
eye  at  or  near  E  in  front  of  its  retina  M.  Divergent  rays  of 
light  from  C  are  brought  to  a  focus  at  H  and  E  by  the  exercise 
of  the  necessary  accommodation  in  the  hyperopic  and  emme- 
tropic eyes,  and  also  at  M  in  the  myopic  eye  without  the  aid 
of  the  accommodation.  Astigmatism,  another  form  of  ame- 
tropia, is  only  a  combination  in  the  same  eye  of  different 
states  of  refraction,  or  of  different  degrees  of  the  same  form  of 
ametropia.  An  emmetropic  fundus  in  a  direct  examination 
with  the  ophthalmoscope  gives  a  clear  erect  image  at  three  or 
four  inches  from  the  eye. 

SPECTACLES. 

For  the  correction  of  the  errors  of  refraction  certain  optical 
aids  are  used  which  are  called  spectacles.  These  consist  of 
suitable  lenses  mounted  in  frames  which  hold  them  in  proper 


68         .  DISEASES  AND  INJURIES  OF  THE  EYE. 

position  before  the  eyes.  The  lenses  are  made  ordinarily" 
from  a  good  quality  of  crown  glass,  or  transparent  quartz, 
the  so-called  pebble  glass.  The  former  is  more  frequently 
used  as  it  presents  the  same  density  throughout  and  is  better 
adapted  for  the  purpose  of  refraction.  The  latter  is  harder 
and  less  likely  to  become  scratched,  but  possesses  no  other 
qualities  which  would  make  it  preferable  to  glass.  The 
frames  may  be  made  of  various  metals  or  of  rubber,  shell,  etc., 
which  have  their  various  advantages  as  regards  weight,  adorn- 
ment, etc.  The  spectacle  frames  are  better  suited  to  their  use 
as  regards  shape,  as  the  lenses  are  held  firmly  in  position 
before  the  eye  by  the  nose-piece  which  rests  upon  the  bridge 
of  the  nose,  and  the  temple  pieces  which  press  the  sides  of  the 
head,  or  hook  behind  the  ears.  Eye-glasses  are  more  suitable 
for  temporary  use,  and  being  attached  to  the  clothing  are 
always  at  hand,  ready  for  use.  The  glass  should  be  placed  a& 
close  to  the  front  of  the  eyes  as  possible  and  yet  not  have  the 
cilia  touch  them.  The  centre  of  the  lens  should  come  directly" 
over  the  centre  of  the  pupil,  unless  it  is  desired  in  certain 
cases  to  get  a  prismatic  effect  also  from  the  glass,  which  i& 
done  by  decentreing  the  lenses  or  placing  them  more  widely 
apart.  Lenses  are  ground  of  various  kinds,  those  most  fre- 
quently used  being  bi-convex,  plano-convex,  bi-concave,  plano- 
concave, convex  or  concave  meniscus  and  cylindric. 

Two  systems  of  numeration  for  spectacle  lenses  are  in  vogue, 
the  old  or  inch,  and  the  metrical  system.  According  to  the 
old  system  a  lens  of  one  inch  focus  was  taken  as  the 
unit  and  the  glasses  numbered  accordingly;  hence  the  focal 
length  was  expressed  by  using  fractions;  but  as  the  inch 
is  not  a  standard  unit  of  measurement,  differing  in  various 
countries,  the  metrical  system  has  received  much  favor.  In 
the  latter  system  a  lens  of  one  metre,  or  39.37  Eng.  inches, 
focal  length  is  taken  as  the  unit;  for  convenience  it  is  called  a 
dioptric  and,  for  brevity,  the  symbol  D  is  used.  As  the 
.  glasses  most  used  are  of  a  greater  refractive  power  than  the 
unit,  the  majority  are  expressed  by  whole  numbers.  A  lens- 
of  half  a  metre  focus,  would  have  twice  the  power  of  the  unit,. 


SPECTACLES. 


69 


and  its  measure  would  be  two  dioptrics  or  2D;  of  one-fourth 
of  a  metre,  four  dioptrics  or  4D;  of  twice  the  length  of  a 
metre,  one-half  a  dioptric  or  expressed  decimally  .5D.  The 
+  sign  before  the  number  of  dioptrics  indicates  a  convex 
glass ;  —  a  concave  lens,  s.  a  spherical,  and  cyl.  a  cylindrical 
lens.  The  numeration  of  the  old  system  can  be  approximately 
converted  into  the  metrical  system  by  multiplying  the  fractions 
of  the  old  system  by  40,  which  is  nearly  the  length  of  a  metre. 
For  instance,  a  lens  -^^  X  40  =  ^,  or  four  dioptrics,  4D ; 
Tgi(j^x40=2,  or  2D.  Conversely  a  lens  of  4  dioptrics  equals 
or  a  lens  of  10  inches  focus. 


-  1 


The  followdng  table 


^ives  the  relative  values  of  each: 


Focus 

Number 

Focus 

Number 

in 

in 

in 

in 

Inches. 

Dioptrics. 

Inches. 

Dioptrics. 

160 

0.25 

9 

4.5 

80 

0.50 

8 

6. 

60 

0.67 

7 

5.5 

60 

0.75 

6>i 

6. 

40 

1.00 

6 

6.5 

36 

1.11 

6K 

7.5 

30 

1.25 

6 

8. 

24 

1.5 

4K 

9. 

22 

1.75 

4 

10. 

20 

2. 

3M 

10.5 

18 

2.25 

33^ 

11. 

16 

2.5 

3M 

12. 

14 

2.75 

3 

13. 

13 

3. 

2M 

14. 

12 

3.25 

^% 

16. 

11 

3.5 

2M 

18. 

10 

4. 

2 

20. 

Spherical  convex  lenses  are  ground  by  the  use  of  a  concave 
tool  which  is  a  section  of  a  sphere.  Spherical  concave  require 
a  convex  tool  for  grinding,  by  which  the  concavity  is  ground 
ihto  the  glass.  The  common  forms  of  lenses  are  as  repre- 
sented in  Fig.  36,  viz.,  the  bi-convex  A,  the  plano-convex  B^ 
the  convex-meniscus  or  periscopic  C,  the  plano-concave  E,  and 
la-concave  D,  and  the  concave  meniscus  F.  Cylindrical  lenses 
are  formed  by  grinding  a  curved  surface  into  the  glass  with  a 


70 


DISEASES  AND  INJURIES  OF  THE  EYE. 


FIG.  36. 


cylindrical  tool,  so  that  in  the  direction  parallel  to  the  axis  of 
the  cylinder  there  is  no  curve,  but  at  right  angles  to  the  axis, 
a  curve  is  formed  which  is  equal  in  focal  length  to  the  curve 
of  the  cylindrical  glass  desired.  Although  simply  refracting- 
the  light  without  formation  of  an  image,  they  are  numbered 
according  to  the  laws  governing  spherical  glasses;  they  may 
be  plano-cylindric,  bi-cylindric,  or,  when  combined  with, 
spherical  glasses,  sphero-cylindric.  Care  is  necessary  in  set- 
ting cylindrical  lenses  in 
spectacle  frames,  as  the 
slightest  deviation  of  the 
axis  of  the  glass  from  the 
meridian  which  it  is  de- 
sired to  correct  will  destroy 
the  whole  effect  of  the 
glass.  Prismatic  lenses  simply  cause  a  change  in  the  direction, 
of  the  light  rays  towards  their  bases,  hence  form  no  images 
and  have  no  foci.  Those  used  for  ophthalmic  purposes  are 
confined  to  some  cases  of  muscular  insufficiency  and  are  very 
weak,  two  to  three  degrees,  as  with  the  increase  of  the  refract- 
ing angle  beyond  this,  the  refraction  of  the  rays  increases 
and  the  diffusion  of  color  becomes  a  serious  inconvenience. 

Stenopaic  glasses  consist  of  a  small  portion  of  transparent 
glass  surrounded  by  an  opaque  surface,  Avhich  prevents  the 
entrance  of  rays  to  the  eye,  except  through  the  narrow  slit  or 
circular  opening;  in  cases  where  the  cornea  presents  many 
irregularities  they  may  be  useful  for  near  vision,  but  the  field 
being  so  much  contracted  by  the  minute  opening  they  are 
rarely  practical  for  distance.  Protective  glasses  are  usually 
colored  glasses,  blue  or  smoke,  with  or  without  refracting- 
curves,  as  desired.  For  purposes  of  protection  simply,  they 
should  be  large  enough  to  well  cover  the  eye,  and,  if  neces- 
sary, additional  glasses  or  other  material  should  be  supplied 
to  prevent  the  entrance  of  light  at  the  side,  which  is  often 
more  annoying  than  that  falling  directly  upon  the  eye.  The 
smoke-colored  glass  is  much  more  suitable  than  blue  glass, 
which  only  excludes  the  orange  rays  of  light  which  have  been 


RANGE  OF  ACCOMMODATION.  71 

supposed  to  be  particularly  diritressing  to  the  sensitive  retina. 
Practice  fails  to  prove  the  peculiar  value  of  blue  glasses  in 
the  treatment  of  these  cases.  The  use  of  protective  glasses 
should  not  be  indulged  in  more  than  is  absolutely  necessary, 
when  the  light  is  not  dazzling,  as  prolonged  use  tends  to 
increase  rather  than  lessen  the  sensitiveness  to  light. 

EANGE  OF  ACCOMMODATION. 

If  objects  are  brought  nearer  than  a  distance  of  twenty 
feet,  the  rays  which  fall  upon  the  eye  are  no  longer  parallel 
but  divergent,  and  the  refractive  power  of  the  media  brings 
them  to  a  focus  behind  the  retina  at  the  conjugate  focus.  To 
bring  this  focus  forward,  then,  so  that  it  will  fall  upon  the 
retina,  the  accommodation  must  be  brought  into  use,  which, 
by  increasing  the  convexity  of  the  anterior  surface  of  the  lens, 
increases  the  refractive  power  and  shortens  the  focal  distance 
until  the  image  falls  upon  the  retina  and  becomes  distinct. 
As  in  Fig.  37,  the  upper  half  of  which  shows  a  normal  eye  in 

^ ^  a  state  of  rest, 

<» /f>(  \  and    the    lower 

—-  ■-— "  -'""'  "^^^  '  (^^^^^S»' I —  \^^\i  in  a  state 
^    J5  y  of  active  accom- 

^\^  y/  modation  for   a 

^«-  37.  near  point  at  A. 

The  divergent  rays  from  A  would  be  brought  to  a  focus  at  G 
behind  the  retina  R  if  the  accommodation  was  not  exercised, 
but  the  increased  refractive  power  resulting  from  the  increased 
convexity  of  the  lens  brings  them  to  a  focus  at  R.  The 
point  ^4  represents  the  nearest  point  of  distinct  vision  and 
is  called  the  near  point  or  punctum  proximum  (P).  The 
greatest  distance  to  which  an  eye  can  see  is  called  the  far 
point  or  punctum  remotum  (-B).  The  range  of  accommoda- 
tion   {A)   is  the  measure  of  the  distance  between  these  two 

points,  and  may  be  expressed  by  the  formula:  J.  =  —  —  — 

R        M 

For  convenience  this  is  measured  by  the  power  of  a  lens  neces- 


72  DISEASES  AND  INJURIES  OF  THE  EYE. 

sary  to  produce  the  same  result.     In  the  emmetropic  eye  this 
is  equal  to  the  distance  of  the  object,  measured  in  inches. 

PEESBYOPIA. 

During  childhood  the  near  point  of  accommodation  is  four 
inches  or  less,  owing  to  the  soft  condition  of  the  lens  fibres 
and  their  consequent  increased  elasticity.  After  ten,  up  to 
twenty  years  of  age,  the  lens  becomes  more  firm,  and  as  age 
advances  the  accommodative  power  diminishes,  owing  to  the 
lessened  elasticity  of  the  lens  and  the  loss  of  power  of  the  cil- 
iary muscle,  so  that  after  forty-five  years  of  age  objects  at  less 
than  eight  or  ten  inches  from  the  eye  are  not  clearly  focused 
upon  the  retina.  This  shortening  of  the  range  of  accommo- 
dation or  receding  of  the  near  point  is,  then,  a  physiological 
change  which  results  from  age.  This  loss  of  accommodative 
power  is  called  presbyopia  (-P'').  When  it  has  reached  a 
certain  degree  the  amount  of  accommodation  necessary  to  see 
an  object  one  foot  from  the  eye  is  -^\,  that  is  ^^  of  that  neces- 
sary to  see  at  one  inch  from  the  eye.  To  see  an  object 
twenty  inches  from  the  eye  would  then  require  an  amount  of 
accommodation  equal  to  a  convex  lens  of  g^^-.  To  see  at  an 
infinite  distance  would  require  one  divided  by  infinity,  ^  or 
no  effort. 

The  monocular  or  absolute  range  of  accommodation  is  that 
obtained  by  testing  each  eye  separately ;  if  both  eyes  are  tried 
together  the  binocular  range  is  obtained,  and  this  is  slightly 
less  than  the  monocular.  The  relative  range  is  that  which  we 
possess  when  the  visual  axes  of  the  eyes  are  fixed  upon  some 
near  object.  The  positive  portion  is  that  lying  between  the 
object  and  the  eye  and  the  negative  that  lying  beyond  the 
object  The  former  may  be  measured  by  a  concave  glass,  the 
latter  by  a  convex  glass.  To  exert  the  eyes  for  any  near  work 
there  must  always  be  a  reserved  amount  of  accommodation  at 
a  given  point  of  convergence,  or  the  eyes  tire  rapidly.  To 
read  comfortably  for  any  length  of  time  the  positive  portion 
of  the  relative  range  of  accommodation  must  be,  at  least,  one- 


PRESBYOPIA. 


73 


lialf  tlie  negative.  The  power  of  accommodation  in  infancy- 
is  |^ ;  at  ten  years  J ;  at  thirty-five  ^  or  less ;  at  forty-five  it  is 
seldom  riiore  than  -^j ;  at  fifty  ^^^  ;  at  sixty  it  is  -^j. 

Diagnosis. — An  arbitrary  standard  of  eight  inches  has  been 
selected  by  Donders  as  the  near  point  in  the  normal  eye, 
hence  presbyopia  appears  as  soon  as  the  accommodation  falls 
short  of  ^,  as  for  fine  work  that  amount  becomes  necessary. 
The  age  at  which  presbyopia  appears  depends  upon  the  gen- 
eral condition  and  upon  the  shape  of  the  eyeball.  If  the 
patient  is  debilitated,  or  the  eyeball  too  short,  it  will  appear 
earlier  than  if  the  patient  is  robust;  or,  if  the  eyeball  be  too 
long,  it  will  be  delayed. 

Symptoms. — The  symptoms  which  indicate  a  condition  of 
presbyopia  are  first,  difficulty  in  reading  fine  print  with  arti- 
ficial light,  followed  by  a  sense  of  strain  in  using  the  eyes  for 
near  work  at  all  times.  Frequently  this  condition  is  accom- 
panied by  an  irritable  state  of  the  eyes  and  smarting  of  the 
lids.  These  symptoms  arise  from  the  fatigue  of  the  ciliary 
muscle  resulting  from  the  effort  to  maintain  the  accommoda- 
tion at  a  nearer  point  than  its  power  will  permit.  If  now  the 
range  of  accommodation  is  tested,  it  will  be  found  that  the 
near  point  has  receded  eleven  or  twelve  inches.  The  reason 
that  this  condition  manifests  itself  in  the  evening  is  because 
the  pupil  is  more  dilated  than  in  daylight,  and  the  larger  the 
pupil  the  more  indistinct  objects  become  when  the  focus  is 
not  exact,  as  the  circles  of  diffusion  become  much  greater. 
The  eye  cannot  sustain  the  accommodative  effort  necessary 
under  these  circumstances  without  weariness  and  consequent 
eye  strain,  hence  the  relief  to  be  obtained  from  the  use  of  a 
convex  glass  should  not  be  delayed.  In  fact,  the  early  use  of 
glasses  to  relieve  the  strain,  results  in  giving  comfort  to  the 
eye,  retains  the  strength  of  the  eye  for  the  future,  and,  at 
the  same  time,  lessens  the  rapid  increase  of  the  presbyopia. 
On  the  other  hand,  if  the  proper  glasses  are  not  used,  the 
presbyopia  increases  more  rapidly,  and  the  ciliary  muscle  is 
often  permanently  weakened. 

Treatment. — No  general  rule  can  be  given  for  the  deter- 


74  DISEASES  AND  INJURIES  OF  THE  EYE. 

mination  of  the  proper  glasses  for  use,  or  at  what  time  they 
sliould  be  put  on.  In  prescribing  glasses  for  presbyopia,  we 
must  take  into  account  the  distance  at  which  the  patient  is  in. 
the  habit  of  using  his  eyes,  and  the  kind  of  work  for  whick 
they  are  employed.  The  reading,  or  sewing  distance,  variea 
with  individuals  according  to  their  habit,  stature,  and  the 
sharpness  of  vision.  The  tall  man  will  read  comfortably  with. 
his  book  at  twenty  inches  from  the  eye,  while  the  small 
woman  finds  her  needle  work  in  the  proper  position  at  eight 
or  ten  inches  away.  The  glass  obtained,  then,  by  calculation, 
is  not  always  the  practical  glass:  for  example,  if  the  near 
point  is  found  at  eighteen  inches,  and  it  is  desired  to  see 
the  object  at  twelve  inches,  then  tV~tV=  3^^  5  this,  then,  should 
be  the  glass  needed,  but  a  trial  with  it  at  12  inches  at  once 
determines  that  it  is  not  to  be  worn  with  comfort,  while  -^  is, 
because  in  this  case  the  positive  amount  of  accommodation  at 
12  inches  is  not  ^  that  of  the  negative  with  -^^  at  that  distance, 
hence  it  must  be  increased.  Again,  the  strength  of  the  glass- 
may,  according  to  the  individual,  have  to  be  diminished,  and 
perhaps  -^^  would  suit  much  better.  Suppose  a  patient  of 
sixty  complains  that  he  can  no  longer  read  %\ith  comfort,  espe- 
cially in  the  evening.  He  reads  ordinary  print  at  thirty  inches,, 
but  not  nearer;  his  former  reading  distance  was  fifteen  inches,, 
then  tV"~  sV^TTTJ  with  a  +30  he  reads  at  the  former  distance, 
but  finds  that  the  glass  does  not  yet  make  his  reading  a 
pleasure,  and  on  trial  a  +24  is  found  to  suit  him  perfectly. 
The  rule,  then,  for  the  prescription  of  glasses  in  presbyopia  ia 
to  give  that  glass  which  makes  ordinary  print  plain  at  the 
usual  reading  distance  of  the  patient,  and  can  be  worn  with 
comfort;  ordinarily  the  first  glass  which  is  necessary  for  pres- 
byopia is  from  -^^  to  3^^  and  the  change  necessary  will  amount 
to  -^  or  -g^-  for  each  two  years  for  patients  under  sixty  yeara 
of  age.  After  sixty  the  glass  must  be  changed  more  fre- 
quently, as  the  increase  in  the  presbyopia  is  nearly  double 
that  of  the  ten  years  preceding.  It  is  important  to  bear  in 
mind  that  the  weakest  glasses  which  enable  a  person  to  do  his 
work  give  him  the  longest  range  of  accommodation.     If  the 


PRESBYOPIA.  75 

glasses  required  are  too  strong,  say  ^  or  i\,  and  tlie  accommo- 
dation is  very  much  weakened  the  range  of  accommodation  is 
necessarily  shortened,  and  patients  who  wear  such  glasses  ar© 
apt  to  complain  because  a  change  of  position  of  the  work,  or  a. 
motion  of  the  head,  throws  it  out  of  focus.  Under  these  cir- 
cumstances the  patient  must  be  satisfied  with  the  inconven- 
ience, or  be  content  to  see  at  a  greater  distance  with  a  weaker 
glass. 

The  presbyopia  of  ametropia  eyes  must  be  corrected  by  first 
correcting  the  ametropia  and  then  obtaining  the  near  point. 
In  hyperopia,  the  presbyopic  glass  is  added  to  that  for  the  cor- 
rection of  the  hyperopia.  For  example,  if  there  is  a  hyperopia 
of  3,1^  in  a  patient  of  fifty,  he  requires  his  near  point  to  be 
brought  up  to  twelve  inches.  A  convex  glass  of  -^^  is  placed 
in  front  of  the  eye  and  a  glass  of  -^^  is  placed  in  front  of  the 
other  glass.  If  this  does  not  accomplish  the  result  a  weaker 
or  a  stronger  glass  may  be  required;  if,  however,  this  is  the 
proper  glass,  then  i^j+sV— tc  ^^  ^  convex  16  will  be 
required  for  near  vision. 

In  myopes,  from  habit  the  working  distance  is  close  to  the 
eye,  and  they  prefer  a  glass  which  will  enable  them  to  see  at 
about  nine  inches.  If  the  myopia  is  J,  then -J  — J  =  ~tsI  in 
this  case,  the  patient  would  have  to  use  a  weaker  concave  glass 
for  near  work.  If  his  myopia  was  -J-  he  would  require  no 
glass;  if  ^^  ^®  would  require,  if  he  desired  to  work  at  eight 
inches,  a  +24;  thus  I— t6=tb,  the  amount  of  presbyopia  if 
the  eye  was  normal,  but  being  myopic  the  glass  then  should 
be  Tg— iV— sV'  ^^®  convex  glass  which  would  give  him 
comfortable  vision  at  eight  inches,  while  the  distant  vision, 
would  still  require  the  use  of  the  concave  glass  which  cor- 
rected his  myopia. 

The  failure  of  the  accommodation  is  not  always  due  to 
normal  causes,  but  is  often  an  indication  of  disease,  as  in 
glaucoma,  where  the  rapid  loss  of  accommodation  is  one  of 
the  earlist  symptoms;  also  in  paralysis  of  the  external  rectua 
muscle,  a  paretic  condition  is  often  observed,  and  in  some 
cases  of  beginning  cataract  there  is  frequently  a  rapid  failure 


"76  DISEASES  AND  INJURIES  OF  THE  EYE. 

of  the  accommodation.  Before  prescribing  glasses  for  pres- 
byopia, investigation  must  decide  whether  the  presbyopia  is 
apparent  or  real. 

HYPERMETEOPIA    OR    HYPEROPIA. 

Hypermetropia  or  hyperopia  [H)  is  a  condition  in  which 
parallel  rays  of  light  are  not  brought  to  a  focus  upon  the 
retina  unless  the  accommodation  is  brought  into  use.  It 
depends  upon  the  antero-posterior  diameter  of  the  eyeball 
being  too  short,  less  than  23  mm.  Under  these  circum- 
•stances  the  focus  of  parallel  rays  is  behind  the  retina, 
«jid  distant  objects  are  not  seen  when  the  eye  is  at  rest.  This 
anomaly  of  refraction  is  dependant  upon  a  congenital  flatten- 
ing of  the  eyeball,  and  was  described  by  Donders  in  1848.  In 
connection  with  the  congenital  form  resulting  from  the  want 
of  proper  development,  there  is  frequently  a  certain  loss  of 
vision,  or  amblyopia,  due  to  the  same  cause. 

Hyperopia  may  be  acquired  by  diseased  conditions  or  opera- 
tions upon  the  cornea  which  result  in  flattening  of  its  normal 
curves.  The  highest  degree  of  acquired  hyperopia  is  that 
following  the  removal  of  the  lens  in  cataract  operations  or 
from  injury,  and  also  from  the  physiological  changes  in  the 
refractive  index  of  the  cornea  and  lens  which  occur  after  sixty 
years  of  age.  Hyperopia  presents  one  of  the  most  common 
forms  of  refractive  error.  In  870  school  children  examined 
by  the  author  523  were  found  hyperopic,  while  only  105 
presented  a  normal  refraction. 

Diagnosis. — In  the  majority  of  cases  of  hyperopia  the 
«xercise  of  the  accommodation  masks  the  condition  so  that 
careful  testing  -of  the  distant  vision  with  convex  glasses,  as 
w^ell  as  examination  with  the  ophthalmoscope,  becomes  neces- 
sary to  determine  the  condition.  Oftentimes  the  facial  condi- 
tion of  the  patient  will  indicate  the  probable  presence  of 
hyperopia,  as  the  eye  appears  flatter  and  smaller,  and  "with 
this  there  is  an  accompanying  want  of  full  development  of  the 
face,  particularly  in  the  malar  region,  and  the  nose  bridge  also 
frequently  presents  a  flattened  condition. 


EYPERMETROPIA  OR  HYPEROPIA.  IT 

Symptoms. — Patients  with  hyperopia  complain  that  in  read- 
ing, writing,  and  all  near  work,  particularly  in  an  artificial  or 
dim  light,  the  vision,  although  at  first  clear,  soon  becomes 
blurred,  and  it  becomes  necessary  to  stop  work  for  a  time 
until  the  eye  regains  its  power.  A  few  moments'  rest  will 
enable  them  to  see  distinctly  again  for  a  short  time,  when  the 
feeling  of  fatigue  and  blur,  and  perhaps  pain  over  the  orbit, 
again  demands  rest  of  the  overtaxed  eyes.  An  examination  of 
tiie  eye  shows  conjunctivitis,  palpebral  hyperaemia  or  blepha- 
ritis, or  perhaps  no  external  appearance  of  disease  is  present* 
Again,  the  patient  avers  that  there  is  nothing  wrong  with  the 
vision,  but  that  the  eyes  appear  weak  when  he  attempts  near 
work,  and  pain  over  the  brow,  severe  headaches,  or  nausea, 
vomiting,  or  vertigo,  may  appear  as  the  result  of  a  strain  in  the 
hyperopic  condition.  As  a  rule  the  amount  of  hyperopia 
present  bears  no  relation  to  the  amount  of  accommodative 
reflex  disturbances  which  arise  in  these  cases,  as  oftentimes,  a. 
high  degree  of  hyperopia  gives  but  slight,  if  any,  incon- 
venience beyond  some  general  indistinctness  of  vision  and  the 
earlier  appearance  of  presbyopia;  whereas  in  other  cases  the 
slightest  degrees  are  often  the  cause,  in  less  robust  and  more 
neurasthenic  patients,  of  severe  disturbances.  The  close 
application  of  the  eyes  for  near  work,  other  things  being  equal, 
will  always  hasten  the  appearance  of  these  symptoms  of 
asthenopia,  or  weak  sight,  which  are  either  from  the  weakness, 
of  the  accommodation,  accommodative  asthenopia,  or  from 
weakness  of  the  recti  muscles,  termed  muscular  asthenopia, 
which  as  frequently  accompanies  the  condition. 

The  cause  of  these  symptoms  lies  in  the  unconscious  effort 
of  accommodation  which  the  patient  is  constantly  making  to 
increase  the  convexity  of  the  lens,  and  thus  increase  the  power 
to  bring  the  rays  of  light  to  a  focus  upon  the  retina,  instead  of 
behind  it,  which  the  defective  refraction  of  the  eye  would  do. 
By  the  active  effort  of  the  accommodation  he  is  just  able  to 
focus  the  rays  so  that  distant  vision  is  rendered  clear,  but  for 
all  near  objects,  the  rays  being  divergent,  an  extra  increase  of 
the   accommodation   becomes   necessary,  so .  that   during   the 


78  DISEASES  AND  INJURIES  OF  THE  EYE. 

^waking  hours  the  accommodative  apparatus  is  constantly  in 
use,  and  consequently  soon  tires  under  the  continued  strain. 
The  effort  to  perform  the  extra  labor  thus  thrown  upon  the 
ciliary  muscle  results  in  hypersemia  of  the  ciliary  body  and  a 
generally  irritable  condition  of  the  eyes,  conjunctivitis,  blepha- 
ritis, etc.,  and  in  many  cases  severe  reflex  symptoms  from 
irritation  of  the  terminal  branches  of  the  ciliary  nerves  in  the 
•ciliary  body,  simulating  cerebral  disturbances,  not  infrequently 
appear. 

The  condition  of  the  health  and  the  amount  of  near  appli- 
cation have  much  to  do  with  the  time  of  the  appearance  of  the 
symptoms  due  to  hyperopia.  If  a  person  has  a  well-toned 
jnuscular  system,  together  "with  an  increased  development  of 
the  circular  fibres  of  the  ciliary  muscle,  which  occurs  in  this 
•case,  as  discovered  by  Iwanoff,  he  may  make  no  complaint  of 
trouble  arising  from  defective  refraction.  If,  however,  the 
Iiealth  fails,  or,  as  frequently  happens,  the  complaint  follows 
prostrating  fevers,  the  puerperal  condition,  mental  shock, 
uterine  affections,  or  the  use  of  the  eyes  for  reading  during  con- 
valescence or  while  in  a  recumbent  position,  or  a  constant  strain 
of  the  muscle  necessitated  by  prolonged  work  at  near  or  fine 
•objects,  as  in  reading,  writing,  drawing  etc.,  the  power  of  the 
accommodation  rapidly  deteriorates  and  aid  is  sought. 

Diagnosis. — With  the  ophthalmoscope,  if  the  mirror  alone 
is  used,  a  rapid  diagnosis  of  hyperopia  may  be  made;  the 
fundus  is  seen  at  a  greater  distance,  18  to  24  inches,  than  in 
the  opposite  condition,  myopia,  and  we  have  an  erect  image, 
which,  as  in  keratoscopy,  moves  in  the  same  direction  as  the 
movement  of  the  observer's  head  or  the  rotation  of  the  mirror. 
In  the  direct  method  the  fundus  is  not  visible  in  the  close 
approximation  of  the  eyes,  unless  the  accommodation  of  the 
observer  is  exercised.  If  the  accommodation  be  relaxed  and 
the  observer  emmetropic,  or  a  proper  correction  made,  the 
convex  glass  rotated  into  position  behind  the  mirror  which 
gives  the  distinct  vision  of  the  fundus,  will  give  also  the 
degree  of  hyperopia,  when  the  mirror  is  brought  as  close  as 
half  an  inch  from  the  cornea.     If  the  distance  is  greater,  or 


EYPERMETROPIA  OR  HYPEROPIA.  79 

1^  inches  from  the  nodal  point  of  the  observed  eye,  then  the 
number  of  the  lens  of  the  ophthalmoscope  is  stronger  by  the 
increased  distance,  represented  by  a  lens  equal  in  focal  length 
to  that  distance.  If  an  examination  at  1^  inches  shows  a 
hyperopia  of  ^,  then  a  lens  of  1  in.  focus  must  be  deducted, 
giving  the  amount  of  hyperopia  as  \  The  image  recedes  the 
nearer  you  approach  the  eye,  and  at  the  same  time  a  larger 
portion  of  the  fundus  becomes  visible,  because  the  rays  from 
the  hyperopia  eye  are  divergent,  and  the  nearer  you  approach 
the  eye  the  more  rays  are  obtained  by  the  eye  of  the  observer.. 
Tlie  image  appears  to  recede  because  we  estimate  the  distance 
by  the  size  of  the  image.  In  the  indirect  method  the  image 
is  larger,  but  a  smaller  portion  of  the  fundus  is  seen.  Here 
the  divergent  rays  coming  from  the  eye  are  caught  by  the 
object  lens,  and  are  brought  to  a  focus  further  behind  the  lens 
and  nearer  to  the  eye  of  the  observ^er,  and  more  rays  are 
collected  from  the  inverted  image  thus  formed. 

In  the  emmetropic  eye  the  vision  is  disturbed  by  placing  in 
front  of  it  a  convex  glass  and  is  not  improved  by  a  concave 
glass,  but  a  hyperopic  eye,  even  if  the  distant  vision  as  deter- 
mined by  the  card  of  test  letters  is  perfect,  will  permit  the 
use  of  a  convex  glass  without  disturbance,  and  if  the  distant 
vision  be  not  normal,  an  improvement  follows  the  use  of  a 
proper  convex  glass.  Tlie  hyperopic  condition  can  thus  be 
determined  in  a  practical  manner  by  the  use  of  test  tvpes  and 
convex  glasses.  If,  then,  the  patient  is  placed  at  the  proper 
distance  for  the  test  card*  as  twenty  feet  for  No.  XX,  and  con- 
vex glasses  are  placed  before  the  eye,  the  strongest  convex 
glass  with  which  he  reads  No.  XX  is  the  measure  of  his 
hyperopia.  Thus,  if,  beginning  with  a  4-y^  and  following  with 
a  stronger  glass  until  +3rV  is  reached  and  the  print  remains  or 
is  made  distinct,  while  the  next  stronger  glass  blurs  the  letter, 
his  hyperopia  thus  determined  is  -^^ ;  this  amount  of  H  thus  dis- 
covered is  termed  manifest  hyperopia  (Jim),  and  is  not  usually 
the  full  measure,  as  the  ciliary  muscle  from  constant  strain 
does  not  relax,  and  the  eye  still  accommodates  somewhat  even 
■when  the  convex  glass  is  placed  before  it.     The  H  which  thus 


of  DISEASES  AND  INJURIES  OF  THE  EYE. 

remains  undetermined  is  termed  latent  HI  and  only  becomes 
known  after  the  ciliary  muscle  is  paralyzed  by  atropine  or 
some  other  mydriatic.  The  strongest  glass  which  then  enables 
the  patient  to  read  the  test  type  at  the  proper  distance  is  the 
measure  of  the  total  amount  of  hyperopia  {Ht^,  and  is  equal 
to  the  sum  of  the  manifest  and  latent  hyperopia.  If  before 
the  use  of  the  mydriatic  the  test  showed  the  Hm  ^-^  and  after 
the  accommodation  was  paralyzed  the  Hi  was  -j^g-,  then  the  HX 
is  the  difference  between  -^^  and  ^V?  o^  -i^'  Usually  the  HI  is 
greater  than  the  Hm^  particularly  in  children  and  young 
people.  In  practice  it  is  not  necessary  to  paralyze  the  accom- 
modation to  obtain  the  full  amount  of  H^  as  it  is  approxi- 
mately determined  by  the  ophthalmoscope,  and  each  eye  should 
be  tested  separately,  and  the  strongest  glass  which  is  borne  is 
the  practical  measure  of  the  Hm.  If  the  glass  during  the 
testing  is  held  for  a  few  moments  before  the  eye,  the  accom- 
modation relaxes  somewhat,  so  that  a  more  accurate  result  is 
obtained.  The  refraction  of  the  two  eyes  is  thus  found  to 
differ  in  many  cases  and  it  may  be  advisable  to  give  the  glasses 
which  correct  the  refractive  power  of  each  eye. 

Donders,  to  whom  we  owe  the  knowledge  of  the  character 
and  symptoms  of  hyperopia,  makes  a  further  classification  of 
the  kinds  of  hyperopia  into  facultative,  where  the  patient  sees 
equally  well  at  a  distance  with  or  without  convex  glasses; 
relative,  where  distant  vision  is  good  without  glasses,  but  is 
accomplished  by  a  convergence  of  the  optic  axes  to  such  an 
extent  as  to  produce  a  convergent  squint,  owing  to  the  relation 
existing  between  the  accommodation  and  the  convergence  of 
the  optic  axes;  and  absolute,  where  neither  distant  nor  near 
vision  is  distinct  without  convex  glasses.  This  further  division 
possesses  no  practical  importance  and  is  but  little  used. 

In  hyperopia  advanced  age  causes  the  demand  for  glasses 
early,  at  thirty  or  thirty-five,  owing  to  the  gradual  impairment 
of  the  power  of  the  ciliary  muscle ;  after  forty  this,  together 
with  the  loss  of  the  elasticity  of  the  lens,  demands  the  use  of 
a  glass  to  correct  the  presbyopia  as  well.  In  some  cases  the 
prolonged  tension  of  the  ciliary  muscle  in  its  efforts  to  lespond 


HYPERMETROPIA  OR  HYPEROPIA.  81 

to  the  frequent  calls  made  upon  it,  results  in  the  production  of 
a  spasmodic  contraction  of  the  muscle  which  causes  spasm  of 
the  accommodation.  This  condition  occurs  more  often  in  weak 
degrees  of  hyperopia,  as  ^\j-  to  -gig,  and  may  mask  the  true 
condition  by  simulating  myopia,  and  the  use  of  convex  glasses 
will  be  refused,  while  a  weak  concave  glass  is  worn  at  the 
expense  of  still  greater  tax  upon  the  accommodation.  This 
condition  will  be  more  fully  considered  in  the  affections  of 
the  ciliary  muscle.  Hyperopia  is  the  common  cause  in  the 
production  of  convergent^  ^traJblsmus,  since  the  act  of  accom- 
modation is  associated  with  contraction  of  the  internal  recti 
muscles,  and  can  only  be  exercised  to  a  limited  extent  without 
converging  the  optic  axes,  and  as  the  ciliary  muscle  is  in 
a  state  of  constant  contraction,  which  must  be  still  more 
increased  for  near  objects,  an  increased  convergence  by  the 
recti  is  brought  about  until  the  patient  converges  more  than  is 
necessary  to  fix  the  eyes  upon  the  object,  and  as  he  can  no 
longer  see  with  both  eyes,  one  or  the  other  deviates  inward, 
while  the  other  fixes  upon  the  object  accurately.  In  time 
this  temporary  deviation  becomes  fixed  and  convergent  stra- 
bismus results. 

Treatment. — The  treatment  of  hyperopia  consists  in  the 
prescription  of  convex  glasses  to  correct  in  whole,  or  in  part, 
the  error  of  refraction,  and  thus  relieve  the  ciliary  muscle  of 
the  necessity  of  extra  work.     Fig.  38  represents  a  hyperme- 

^^<'-=:^^  tropic    eye    at 

A A   /yl  \\       reat,    in  which 

B  ^^"^T^^^r^^   7  /     convergent  rays 

-4.  ^      ^K,.^^^''^        ^^  are  refract- 

^^•^-  ed    to    a    focus 

upon  its  retina  H,  parallel  rays  BB  being  under  the  same 
condition  refracted  to  a  focus  at  the  normal  position  of  the 
retina  E;  by  the  interposition  of  a  convex  lens  the  parallel 
rays  are  rendered  convergent  and  thus  enter  the  eye  in 
such  a  condition  as  permits  the  formation  of  a  distinct 
image  upon  the  actual  retina  H.      The  power   of  the   lens 

6 


82  DISEASES  AND  INJURIES  OF  THE  EYE. 

required,  and  the  necessity  for  wearing  it  at  all  times,  or 
only  for  near  work,  will  depend  upon  the  individual  peculiar- 
ities of  each  case.  In  some  cases  where  the  vision  is  acute  for 
both  near  and  distant  objects  the  accommodation  does  not  seem 
to  suffer  from  the  prolonged  tension.  Here  glasses  may  not 
be  needed  until  the  age  of  thirty  or  thirty-five,  when  the  early 
appearance  of  presbyopia,  as  denoted  by  the  removal  of  the 
near  point  beyond  ten  or  twelve  inches,  will  require  a  convex 
glass  for  reading.  The  convex  glass  which  corrects  the  whole 
of  the  H  would  seem  theoretically  to  be  the  glass  to  be  worn, 
but  practically  this  glass  is  too  strong,  as  the  ciliary  muscle 
seems  to  have  acquired  a  certain  amount  of  tension  which 
does  not  relax  under  the  use  of  the  glass.  Hence  the  rule  is 
to  give  that  glass  which  corrects  the  whole  of  tjie  .manifest  ij, 
Und  a  part,  uanally  oniJ-fnTirth^  of  thft  latPTit  The  patient  is 
asked  to  read  No.  XX  of  Snellen's  test  types  at  twenty  feet 
distant ;  he  does  so  readily.  Now  place  before  the  eyes  a  weak 
convex  glass,  say  -5^^,  and  if  the  letters  still  remain  clear  try  a 
still  stronger  one  until  we  find  he  reads  the  test  -udth  3^^-;  try- 
ing the  next  glass  we  find  that  it  blurs  the  vision  somewhat. 
We  have  determined  that  his  Hm  is  -gig- ;  he  is  then  asked  to 
read  No.  1  test  type  at  twelve  inches  with  this  glass ;  if  he  can 
do  so  with  facility  he  is  given  this  glass,  a  convex  30,  which 
he  is  directed  to  use  for  all  near  work.  Tested  with  the 
ophthalmoscope  his  H  is  found  to  be  y'^;  we  have  then  cor- 
rected only  part  of  his  error.  Now  the  glass  prescribed  may 
relieve  his  symptoms  entirely,  or  it  may  be  necessary  for  him 
to  wear  the  glasses  constantly  for  both  near  and  distant  vision. 
If  the  latter  becomes  necessary,  then  he  will  be  required  to 
change  the  glasses  for  stronger  ones  in  a  short  time  as  they 
do  not  neutralize  his  latent  hyperopia,  and  this  will  gradually 
become  manifest  and  his  asthenopic  symptoms  will  again 
appear  and  r^a^ire  a  stronger_glasg.  These  changes  will 
have  to  be  repeated  until  after  a  few  months  the  whole  amount 
of  H  becomes  manifest  and  is  corrected. 

Iji^chjMren jtjsjbetter  to  correct  the  fiill  amount  as  deter- 
mined by  the  ophthalmoscopvi,  or  imaer  the  paralyzing  effect 


MYOPIA.  83 

of  atropine,  as  the  vision,  which  is  often  poor  in  these  cases, 
s^ms  to  improve  from  the  apparent  improvement  in  the  tone  of 
the  eye  resulting  from  the  use  of  the  glasses.  In  adults  the 
correction  of  the  whole  amount  as  determined  by  these  methods 
causes  too  much  inconvenience.  If  in  the  test  the  distant 
vision  is  not  acute  but  made  so  or  improved  by  the  convex 
glasses,  then  the  full  amount  of  H  should  be  corrected  and  the 
glasses  ordered  to  be  worn  constantly  as  a  rule.  The  glasses 
should  be  continually  worn  in  all  cases  where  the  .ff^is_more 
than  ^jJg-  ^^'^  i^  weakly  subjects  where  it  is  ftvpn  less  than  thiSf 
particularly  if  the  rectL-muscles  are  weak.  With  the  appear- 
ance of  presbyopia,  the  patient  will  have  to  use  two  pairs  of*! 
glasses,  one  for  distance  which  corrects  his  hyperopia  and  a  r 
stronger  one  for  near  vision,  which  corrects  both  the  hyperopia  J 
and  presbyopia.  In  many  cases  of  H,  particularly  of  high 
degree,  the  vision  is  not  made  acute  by  any  glasses,  a  certain 
amount  of  congenital  amblyopia  being  present  from  the  unde- 
veloped condition  of  the  eye.  In  many  cases  the  asthenopic 
symptoms  occasioned  by  the  over-strained  and  often  irritable 
ciliary  muscle  do  not  subside  upon  the  prescription  of  glasses, 
but  will  require  some  medicinal  treatment. 

MYOPIA. 

Myopia  [31)  or  nearsightedness  is  a  condition  exactly  the 
opposite  of  hypermetropia,  the  eye  being  too  long,  or  more 
than  23  mm,  in  its  antero-posterior  diameter.  Hence, 
parallel  rays,  when  the  eye  is  in  a  state  of  rest,  are  brought  to 
a  focus  in  front  of  the  retina.  If  the  accommodation  is  exer- 
cised it  serves  only  to  bring  the  focus  of  the  rays  still  further 
in  front  of  the  retina.  The  far  point  of  the  myopic  patient 
must  then  approach  closer  to  the  eye,  as^an  object  to  be  per- 
ceived must  be  nearer  to  the  eye  than  infinity,  or  twenty  feet, 
so  that  the  rays  will  be  divergent  instead^  pf  parallel.  The 
far  point  will  thus  approach  nearer  and  nearer  to  the  eye  as 
the  degree  of  myopia  increases.  Myopia  is  occasionally  physi- 
ological  or    congenital.       More   frequently   the   tendency   is 


84  DISEASES  AND  INJURIES  OF  THE  EYE. 

inherited,  but  it  is  commonly  acquired,  and,  except  in  very 
slight  degrees,  is  progressive  with  age.  The  stronger  the 
degree  of  myopia  the  more  liable  it  is  to  increase,  especially 
between  the  ages  of  twelve  and  twenty-five  years.  The  eye- 
ball is  usually  more  prominent,  from  its  egg-like  shape,  and 
its  movements  more  impeded  than  in  the  emmetropic  or  hyper- 
metropic eye,  and  when  the  eye  is  directed  inwards  the  outer 
canthus  is  filled  by  the  lengthened  eye-ball.  The  pupils  are 
usually  more  dilated  than  in  the  normal  eye,  and  when  tiying 
to  look  at  distant  objects  the  eyelids  are  partially  closed, 
thus  lessening  the  circles  of  diffusion  on  the  retina  and  giving, 
more  distinct  vision. 

Causes. — The  causes  which  give  rise  to  myopia  are,  as  yet, 
not  fully  understood.  While  it  may  be  congenital,  the  ten- 
dency is  often  hereditary.  It  is  most  frequently  acquired 
between  the  ages  of  seven  and  fifteen,  very  rarely  appearing 
after  twenty -five  years  of  age.  It  is  a  diseased  condition  of 
the  eyes  occurring  in  childhood  and  early  adult  life,  seldom 
increasing  after  twenty- five,  unless  from  want  of  proper 
hygiene  of  the  eyes,  prostrating  illness,  general  enfeeblement- 
of  the  health  and  loss  of  tone  of  the  muscular  system.  If  the 
sight  in  childhood  is  imperfect  from  any  cause,  such  as  opaci- 
ties of  the  cornea  and  lens,  choroidal  disease  or  astigmatism, 
myopia  is  induced  from  objects  being  brought  close  to  the 
eyes  to  obtain  a  larger  image  upon  the  retina. 

Myopia  may  be  caused  also  by  an  increase  in  the  refractive 
power  of  the  lens  or  cornea.  If  the  cornea  becomes  more 
convex,  as  in  conical  cornea,  the  focal  point  lies  in  front  of  the 
retina.  In  commencing  cataract,  a  swelling  of  the  lens  or  an 
increase '  in  its  ^  refractive  power  causes  a  certain  degree  of 
myopia,  as  also  does  spasm  of  the  ciliary  muscle,  which  pro- 
duces and  maintains  an  increased  convexity  of  the  lens. 

The  more  frequent  causes  which  determine  the  inception 
and  progress  of  myopia  are  those  arising  from  prolonged  use 
of  the  eyes  in  looking  at  objects  held  a  short  distance  away. 
The  constantly  increasing  proportion  of  myopes  among  school 
children  and  students  shows  that  defects  in  our  educational 


MYOPIA— THE  PATHOLOGICAL  CHANGES.  85 

system  have  much  to  do  with  its  origin  and  progress.  The 
arrangement  of  the  light  and  desks,  the  posture,  etc.,  of  the 
child  or  student,  increase  or  lessen  the  tendency  to  this  disease. 
The  flickering,  dull  or  otherwise  poor  light,  or  that  coming 
from  the  side  so  as  to  throw  a  portion  of  the  page  in  the 
shadow ;  the  lowness  of  the  desk  which  requires  a  bent  posi- 
tion upon  the  part  of  the  child ;  reading  in  the  prone  position, 
or  after  a  hearty  meal ;  the  imperfect  print  of  text-books,  or 
the  difficult  characters  of  music,  Greek  or  German,  with  many 
others,  are  highly  productive  of  many  cases  of  myopia. 

The  effect  produced  upon  the  eyeball  which  results  in  the 
elongation  of  its  axis  is  explained  upon  the  ground  that  all 
close  application  of  the  eyes  is  accompanied  by  an  increase  in 
the  ocular  circulation,  and  if  the  return  flow  is  interfered  with 
by  the  position  of  the  head  whUe  stooping  over  the  book  or 
"work,  choroidal  congestion  with  increased  intra-ocular  tension 
results.  This  causes  a  predisposition  to  the  softening  of 
the  choroid  and  sclera.  Together  with  this,  the  effort  to 
fix  the  eyes  upon  close  objects  is  accompanied  by  strong 
efforts  at  convergence  and  accommodation.  This  produces 
pressure  upon  the  eyeball  by  the  tension  of  the  internal  rectus, 
which  is  counterbalanced  by  the  external  rectus,  and  the  fluid 
pressure  is  transmitted  to  the  posterior  portion  of  the  eyeball, 
which  is  unprotected,  and  a  slight  bulging  of  the  sclera  at  this 
point  results.  If  these  efforts  are  prolonged  and  rapidly  recur 
and  the  sclera  is  correspondingly  weak,  the  stretching  becomes 
permanent,  and  although  the  eye  may  have  been  originally 
emmetropic,  or  slightly  hypermetropic,  it  may  thus  become 
myopic.  It  is  evident  that  if  the  disease  once  be  started  it 
will  tend  to  rapidly  increase  the  lengthening  of  the  eyeball 
and  the  degree  of  myopia.  The  proportionate  elongation  of 
the  optic  axis  to  the  degree  of  myopia  has  been  tolerably  well 
determined  by  Loring  and  others  and  is  as  follows:  an  elonga- 
tion of  .22  mm.  produces  a  myopia  of  ^^i  .27  mm.  of  -^^i  .37 
mm.  of  -gJ^;  .46  mm.  of  -^^i  .56  mm.  of  ^^5  '63  mm.  of  y^^;  .82 
mm.  of  -^^;  .97  mm.  of  y^J  1-06  mm.  of  ^ij-;  1.17  mm.  of  ^VJ 
1.31  mm.  of  I ;  1.5  mm.  of  ^;  2.07  mm.  of  -J;  2.56  mm.  of  \; 


86 


DISEASES  AND  INJURIES  OF  THE  EYE. 


3.34  mm.  of  ;^;  4.81  of  ^;  8.61  mm.  of  ^.  Very  slight  degrees 
of  myopia  are  thus  seen  to  be  attended  by  an  apparently 
insignificant  increase  in  the  length  of  the  eyeball,  only  .5  mm. 
Tip  to  ^ly.  The  effect,  however,  has  been  a  serious  one  to  the 
patient,  as  his  far  point  has  been  brought  from  infinity  to 
within  twenty-four  inches  of  the  eye.  As  the  elongation  of 
the  eyeball  increases,  the  far  point  rapidly  approaches  the  eye, 
as  in  a  myopia  of  ^  the  eyeball  is  lengthened  5  mm.  or  24- 
lines,  and  the  far  point  is  now  but  three  inches  from  the  eye. 
In  some  cases  the  myope  may  derive  some  compensation  from 
the  fact  that  he  sees  more  distinctly  and  works  at  a  closer 
Tange  with  more  comfort  than  an  emmetropic  eye,  because  he 
does  not  use  his  accommodation ;  but,  contrary  to  the  popular 
idea,  the  myopic  eye  is  not  a  strong  eye,  but  a  diseased  one, 
and  but  few  of  its  many  subjects  ever  have  even  the  Batisfac- 
tion  of  comfortable  near  work. 

THE  PATHOLOGICAL  CHANGES 

in  the  choroid,  sclera  and  retina  become  apparent  even  in  the 
slighter  degrees  of  myopia,  as  we  frequently  find  them  in  -^^ 
or  less,  while  they  become  much  more  manifest  and  more 
grave  "with  each  additional  degree  of  elongation.  These 
changes  consist  in  a  stretching  of  the  sclera,  choroid,  and 
retina,  and  a  consequent  atrophic  con- 
dition of  the  delicate  tissues  of  the 
latter.  The  sclera  is  expanded  and  thin 
throughout  its  whole  extent,  on  the  tem- 
poral more  than  on  the  median  side,  and 
more  markedly  at  the  posterior  pole 
than  elsewhere,    as   shown  in   Fig.    89, 

FIG  39  . 

which  represents  a  section  of  a  strongly 
myopic  eyeball  with  posterior  bulging.  These  changes  affect 
particularly  the  optic  nerve  entrance,  causing  a  displace- 
ment of  the  optic  nerve  somewhat  to  the  nasal  side. 
A  separation  of  the  two  nerve  sheaths  takes  place  in  close 
proximity  to  the  optic  nerve  entrance,    as   the   outer   sheath 


MYOPIA— THE  PATHOLOGICAL  CHANGES. 


87 


FIG.  40. 


is  continuous  with  the  cater  portion  of  the  sclera,  the  inner 
sheath  being  closely  united  to  the  nerve.  The  subarachnoidal 
space  becomes  much  wider  and  the  posterior  portion  of  the 
eyeball  presents  a  conical  appearance.  The  thinned  sclera 
sinking  into  this  space  constitutes  the  so-called  posterior 
staphyloma,  which  becomes  very  apparent  in  high  degrees 
of  myopia.  The  anterior  portion  of  the  choroid  remains 
normal,  but  as  it  approaches  the  expanded  portion  it  becomes 
thinner  and  atrophied.  There  is  in  the  majority  of  cases 
a  slow  inflammatory  condition  of  this  portion  of  the  choroid, 
which  has  been  termed  sclerotico-choroiditis 
posterior.  This  results  in  the  thinning  of 
the  portion  of  the  choroid  adjacent  to  the 
optic  disc,  until  it  appears  as  a  transpar- 
~r  ent  membrane  devoid  of  blood-vessels  and 
capillaries,  so  that  the  white  underlying 
sclera  becomes  visible.  This  choroidal 
atrophy  may  present  the  appearance  of  a 
crescent  about  the  optic  disc  as  in  Fig.  40,  and  usually 
appears  on  the  temporal  side,  and,  extending  towards  the 
macula  lutea,  gives  to  the  optic  disc  a  jagged  and  irregular 
appearance.  In  high  degrees  of  myopia 
the  atrophic  portion  encircles  the  whole 
optic  disc  as  in  Fig.  41,  and  gives  to  it  a 
much  larger  appearance  than  normal. 
If  the  myopia  progresses  rapidly  other 
portions  of  the  choroid  become  involved 
in  the  inflammatory  process,  and  atrophic 
patches  result;  or  the  vitreous  becomes 
involved  and  opacities  of  varying  size 
appear,  which  interfere  with  the  vision  of  the  patient;  or 
the  vitreous  itself  may  become  fluid.  If  the  opacities  are 
very  fine  and  diffuse,  the  patient  will  be  annoyed  by  the 
miiscce  voliiantes  which  myopic  patients  frequently  complain 
of,  although  no  impairment  of  the  vision  results.  These 
floating  specks  often  indicate  an  increase  in  the  myopia. 
If  the  opacities  are  larger  or  float  through  the  liquid  vitreous, 


FIG.  41. 


OO  DISEASES  AND  INJURIES  OF  THE  EYE. 

they  interfere  very  materially  with  the  vision.  The  retina, 
in  participating  in  the  choroidal  stretching,  lessens  the 
visual  acuity  by  the  disturbance  of  its  elements.  The  rods 
and  cones  being  stretched  apart  occasion  breaks  in  the  outline 
of  objects,  a  condition  termed  metamorphopsia,  and  the 
retinal  vessels  also  become  more  prominent  and  straighter 
in  their  course.  Being  loosely  attached  to  the  choroid,  the 
retina  is  liable  to  detachment,  particularly  in  high  degrees 
of  myopia,  when  its  natural  support,  the  vitreous,  is  lost  by 
the  changes  which  take  place  in  it.  This  forms  one  of  the 
most  grave  complications  arising  in  myopia.  Other  changes 
which  result  from  this  disturbance  are  retraction  of  the  iris, 
lens  and  anterior  portion  of  the  ciliary  body,  the  deep- 
ening of  the  anterior  chamber  in  myopia  being  thus  accounted 
for.  The  nutrition  of  the  lens  may  also  be  affected,  and  cata- 
ract, usually  beginning  at  the  posterior  pole,  folloAvs.  These 
results  arising  from  the  diseased  condition  of  the  eye,  render 
the  early  recognition  of  myopia  and  its  proper  treatment  of 
the  utmost  importance  to  the  patient  as  regards  his  future 
vision,  as  these  changes  frequently  deA^elop  after  slight 
injuries,  prolonged  use  of  the  eyes  in  reading  or  in  near  work, 
and  the  use  of  improper  glasses,  and  again  arise  without 
apparent  cause  and  progress  until  the  vision  is  partly  or  com- 
pletely lost. 

The  symptoms  which  accompany  these  changes  may  be  very 
slight;  there  is  usually,  however,  more  or  less  sensitiveness  to 
light,  which  may  increase  to  such  a  degree  as  to  demand  entire 
exclusion  of  light  from  the  eyes.  The  eye  presents  an 
irritable  appearance,  and  intense  pain  may  accompany  its  use, 
though  more  frequently  the  pain  is  described  as  of  a  dull, 
aching  character,  and  is  often  referred  to  the  orbit. 

Diagnosis. — The  diagnosis  is  readily  made  by  testing  the 
far  and  near  points  of  vision.  If  the  patient  cannot  see 
distant  objects  and  can  read  No.  1  Jaeger  or  1^  Snellen  of  the 
small  types  well,  but  not  beyond  eight  inches,  this  is  evidently 
his  far  point,  and  if  he  cannot  read  the  ordinary  test  types  for 
distance,  a  concave  glass  is  tried  and  the  weakest  concave  glass 


MYOPIA— DIAGNOSIS.  8^ 

■mth.  whicli  he  gets  the  best  vision  is  the  measure  of  his  myopia ; 
thus,  if  he  cannot  read  the  test  type  without  a  glass,  but  can 
do  it  with  a  concave  ^,  then  his  myopia  is  ^ ;  or,  if  the  removal 
of  the  glass  somewhat  from  the  eye  does  not  lessen  the  vision, 
the  glass  is  then  too  strong  and  a  weaker  one  must  be  tried. 
If,  however,  this  glass  seems  to  suit  the  different  objects,  he  is 
myopic  ^,  and  a  concave  ^  placed  in  front  of  such  an  eye  will 
cause  parallel  rays  to  be  divergent  as  if  they  came  from  a 
distance  of  only  eight  inches,  and  would  thus  make  distant 
objects  distinct. 

The  ophthalmoscope  affords  a  ready  and  accurate  method  of 
diagnosing  this  trouble.  If  the  mirror  is  used  without  the  lens 
at  eighteen  inches  or  two  feet  from  the  patient,  an  inverted 
image  is  seen  which  moves  in  an  opposite  direction  to  the  move- 
ment of  the  head  of  the  observer.  This  is  due  to  the  crossing 
of  the  emergent  rays  before  .they  meet  his  eye.  If  now  the 
mirror  is  brought  close  to  the  eye,  the  weakest  concave  lens 
which  will  show  the  smallest  retinal  vessels  near  the  disc  will 
give  the  degree  of  myopia,  provided  the  observer's  accommo- 
dation is  relaxed.  The  change  in  the  fundus  which  is  discov- 
erable by  the  ophthalmoscope,  is  the  choroidal  atrophy  about 
the  optic  nerve,  as  already  stated.  This  is  usually  crescentic 
and  on  the  temporal  side,  but  may  appear  on  the  other  side, 
or  encircle  the  whole  disc. 

In  keratoscopy  the  image  of  light  and  shade  moves  in  the 
same  direction  as  that  in  which  the  concave  mirror  is  rotated, 
and  the  rapidity  of  movement  and  curvature  of  the  shadow 
are  the  same  in  all  meridians  in  cases  of  simple  myopia. 

Treatment.  —  The  treatment  of  myopia  should  be  both 
prophylactic  and  palliative  or  corrective.  In  the  prevention 
of  myopia  and  lessening  of  its  progress  much  may  be  accom- 
plished by  the  proper  care  of  the  eye.  There  is  no  doubt  that 
myopia  is  produced,  or  at  least  greatly  increased  in  school 
children  by  want  of  proper  arrangement  of  the  light,  the 
height  of  the  desks,  and  the  print  of  text-books.  The  light 
should  be  good,  the  seats  so  arranged  that  the  light  comes 
from  the  left,  and  the  desks  of  such  a  height  as  to  remove  the 


90  DISEASES  AND  INJURIES  OF  THE  EYE. 

temptation  to  stoop.  Beading  or  writing  in  a  dull  or  flicker- 
ing ligM  must  not  be  permitted,  and  the  amount  of  reading 
must  be  regulated,  as  this  class  of  cases  are  apt  to  consume 
time  in  reading  which  should  be  used  for  developing  the 
muscular  system.  Where  a  myopic  tendency  has  been  exhib- 
ited in  children  who  have  suffered  from  exanthematous  diseases, 
reading  and  attendance  at  school  should  not  be  allowed  until 
full  bodily  strength  has  been  restored.  Where  vision  is 
defective  from  astigmatism,  or  spasm  of  the  accommodation 
is  present,  the  correction  by  proper  glasses  should  be  made. 
In  reading,  the  book  should  be  held  as  far  from  the  eye  as 
possible  and  yet  allow  of  distinct  vision,  and  when  the  eye 
tires,  the  book  should  be  laid  aside  and  the  eyes  rested.  In 
cases  where  the  trouble  is  progressive  and  there  is  much 
choroidal  congestion,  the  use  of  the  eyes  should  be  stopped 
until  the  condition  improves. 

Atropine,  by  paralyzing  the  ciliary  muscle,  may  prevent  the 
rapid  increase  of  myopia  where  it  is  accompanied  by  spasm  of 
the  accommodation.  Such  remedies  as  Agaricus,  Belladonna, 
Gelsemium,  Physostigma,  Jaborandi,  Lilium  tigrinum  and 
Duboisia,  when  properly  prescribed,  do  much  towards  improv- 
ing the  condition  of  the  myopic  eye  by  correcting  the  irregular 
action  of  the  ciliary  muscle.  Other  secondary  disturbances 
of  the  optic  nerve,  retina,  and  choroid  should  be  combatted 
by  such  remedies  as  Belladonna,  Phosphorus,  Gelsemium, 
Macrotin,  etc. 

The  palliative  treatment  consists  in  the  use  of  proper 
concave  glasses  to  correct  the  error  of  refraction.  The 
manner  in  which  concave  glasses  correct  the  error  of  refrac- 
tion is  readily  explained  by  reference  to  Fig.  42,  which 
represents  a  myopic  eye  in  a  state  of  rest,  and  rays  from  its 
far  point  B  are  brought  to  a  focus  upon  the  retina  at  M. 
Parallel  rays  A  A,  however,  are  refracted  to  a  focus  at  E^  the 
position  of  the  retina  of  an  emmetropic  eye,  and  in  front  of 
the  myopic  retina.  If  now  the  proper  coucave  lens  is  placed 
upon  the  eye  the  rays  A  A  are  rendered  convergent,  and  enter 
the  eye  in  same  direction  as  if  coming  from  B,  and  are  thus 


MYOPIA— TREATMENT.  91 

converged  upon  tlie  retina  at  M.  In  mild  degrees  of  myopia 
without  tissue  change,  the  weakest  glass  which  gives  clear 
vision  of  distant  objects  may  be  worn  without  danger,  and 
have  no  effect  upon  the  progress  of  the  myopia.  In  all  cases 
where  the  myopia  is  less  than  y^g-  the  glasses  should  not  be 
worn  for  near  vision.  In  higher  degrees  than  ^^,  the  glasses 
may  be  worn  for  near  vision,  as  they  remove  the  near  point 

farther  from 

the  eye  and 

•^  ^  — — — — ^^^^^^— ,„.     ^   \  ,  thus    lessen 


the  conver- 
gence of  the 
eyes  and  the 

tension  of  the  recti  muscles,  so  that  patients  are  no  longer 
tempted  to  stoop.  These  glasses  must  be  weaker  than  those 
which  are  used  for  distance,  from  the  fact  that  glasses 
which  correct  the  whole  myopia  would  require  the  exercise 
of  the  full  accommodation  for  near  objects,  and  as  the  accom- 
modation is  usually  weakened,  the  effort  would  only  lead 
to  overstraining  and  thus  increase  the  trouble.  If  a  patient 
with  myopia  reads  No.  XX  test  type  with  — ^,  the  weakest 
glass  which  makes  the  print  clear,  and  it  is  desired  to  adapt 
glasses  for  reading  music,  sewing,  or  other  special  work 
at  a  distance  of  two  feet,  then  the  glasses  desired  will  be 
■jJj— jV=jV  -"-f  ^^®  myopia  is  -|,  the  far  point  then  is  only  six. 
inches  from  the  eye,  and  glasses  will  be  required  which  will 
enable  him  to  read  at  twelve  inches;  then  -^— yV=7V  "^i^l  ^® 
the  glasses  required.  Each  eye  should  be  tested  separately, 
and  when  one  eye  is  more  myopic  than  the  other,  the  least 
myopic  eye  decides  the  number  of  the  glass.  If  different 
glasses  are  prescribed  for  the  two  eyes,  the  images  formed 
upon  the  two  retinae  differ  in  size  and  cause  confusion. 

The  same  glasses  may  be  worn  for  both  near  and  distant 
vision  when  the  myopia  is  slight,  the  range  of  accommodation 
good,  and  the  eya  perfectly  healthy.  Glasses  for  near  vision 
may  also  be  given  when  the  myopia  is  great,  to  prevent  the 
convergence  of  the  optic  axes  and  lessen  the  tension  of  the 


^2  DISEASES  AND  INJURIES  OF  THE  EYE. 

accommodation,  and  also  where  there  is  much  asthenopia. 
•Glasses  should  not  be  allowed  in  mild  degrees  of  myopia,  say 
■^  to  -g^g,  either  for  distant  or  near  vision,  particularly  in 
young  persons.  Where  necessary,  a  glass  may  be  given  to  be 
Tised  occasionally  for  distant  vision.  Glasses  should  also  be 
forbidden  where  there  is  much  amblyopia,  as  in  cases  where 
there  are  extensive  changes  in  the  sclera  and  choroid.  Muscu- 
lar asthenopia  from  insufficiency  of  the  internal  recti  muscles 
is  a  common  accompaniment  of  myopia,  and  if  not  relieved  by 
the  use  of  proper  concave  glasses  and  such  remedies  as  Argen- 
tum  nitricum,  Gelsemium  and  Merc,  peren.  may  require 
tenotomy  of  the  external  rectus  of  one  or  both  eyes,  particu- 
larly if  the  weakness  is  sufficient  to  cause  a  divergent  squint. 
Prismatic  glasses,  the  bases  of  the  prisms  being  turned  toward 
the  nose,  are  serviceable  in  some  cases  to  relieve  the  aching 
from  muscular  insufficiency,  and  may  be  used  separately  or 
combined  with  the  concave  glass.  The  light  in  passing 
through  the  prism  is  refracted  towards  its  base  and  thus  gives 
the  rays  from  a  certain  near  point,  a  direction  as  if  they  came 
from  a  greater  distance,  and  thus  lessens  the  necessity  for 
•convergence  of  the  optic  axis. 

As  the  myopic  patient  advances  m  life,  if  the  myopia  has 
l^een  of  moderate  degree,  he  is  enabled  to  work  without  glasses 
Inhere  other  persons  with  emmetropic  eyes  require  the  use  of 
convex  glasses.  In  the  higher  degrees,  the  physiological 
decrease  of  the  power  of  the  lens  may  require,  however,  a 
iveaker  concave  glass  for  near  vision,  while  the  patient  will 
retain  his  former  glasses  for  distance.  He  may  even  require 
•concave  glasses  for  distant  vision  and  a  weak  convex  glass  for 
near  vision.  These  may  be  combined  by  grinding  the  upper 
part  of  the  lens  for  distance  and  the  lower  part  for  near  vision, 
forming  the  so-called  glasses  of  double  focus  or  pantoscopio 
glasses. 

ASTIGMATISM. 

Astigmatism  [A)  is  that  condition  of  the  refraction  of  the 
eye  where  the  rays  are  not  brought  to  a  distinct  focus,  the 


ASTIGMA  TISM—CA  USES.  93 

image  of  a  luminous  point  appearing,  not  as  a  point  upon  the 
retina,  but  as  an  elongated,  oval,  or  luminous  line.  It  is  due 
to  the  fact  that  the  curvature  of  the  cornea  is  not  the  same  in 
every  direction.  In  the  normal  eye  there  is  a  slightly  greater 
curvature  of  the  vertical  than  of  the  horizontal  meridian  of  the 
cornea,  and  when  the  optical  effect  of  this  difference  becomes 
perceptible  astigmatism  exists.  In  case  the  horizontal  meridian 
has  a  normal  curve  of  31  mm.  and  the  vertical  meridian  pre- 
sents a  shorter  curve  of  only  28  mm.,  then  the  horizontal 
meridian  will  be  emmetropic,  and  the  rays  of  light  passing 
through  it  will  be  brought  to  a  focus  upon  the  retina,  while 
the  vertical  meridian  will  be  myopic  and  the  rays  be  focused 
in  front  of  the  retina.  The  distance  between  these  two  focal 
points  gives  the  degree  of  astigmatism.  The  image  thus 
formed  upon  the  retina  will  not  be  distinct,  but  blurred  and 
distorted.  Astigmatism,  then,  depends  upon  a  difference  in 
the  curvature  of  the  meridians  of  the  eye.  The  vertical,  hori- 
zontal, or  intermediate  meridians  do  not  present  a  perfectly 
spherical  curve,  or  one  of  these  meridians  may  be  more  convex 
than  the  others. 

Causes. — This  irregularity  is  usually  congenital  and  heredi- 
tary, but  may  be  acquired  after  injuries,  or  operations  involv- 
ing the  cornea,  such  as  cataract  extraction  or  iridectomy. 
Some  cases,  however,  are  undoubtedly  due  to  similar  conditions 
of  curvature  in  the  meridians  of  the  lens,  which  may  arise 
from  the  irregular  action  or  spastic  contraction  of  certain  fibres 
of  the  ciliary  muscle. 

Astigmatism  due  to  difference  in  the  curvature  of  sections 
of  the  cornea  is  termed  regular,  and  is  susceptible  of  correc- 
tion by  cylindrical  glasses,  while  that  condition  where  irregu- 
larities in  the  curve  of  single  meridians  occur  from  injury  or 
disease  of  the  cornea,  such  as  ulcerations,  or  from  displacement 
of  the  lens,  is  called  irregular  astigmatism.  Irregular 
astigmatism  sometimes  causes  two  or  more  images  in  one  eye, 
or  monocular  polyopia.  It  arises  from  irregularities  in  the 
cornea,  or  in  the  structure  of  the  lens.  The  emmetropic  eye 
may  have  a  certain  amount  of  irregular  astigmatism  caused  by 


u 


DISEASES  AND  INJURIES  OF  THE  EYE. 


variations  in  the  different  sectors  of  the  lens.  The  vision  in 
this  class  of  cases  is  improved  by  looking  through  a  small 
opening  in  an  opaque  disk,  but  cannot  be  wholly  corrected  by 
glasses,  although  slight  improvement  is  gained  by  the  trial  of 
concave  or  convex  lenses. 

In  regular  astigmatism  the  two  principal  meridians,  that  of 
the  greatest  and  that  of  the  least  refractive  power,  are  at  right 
angles  to  each  other,  or  nearly  so,  and  the  one  having  the 
.  greatest  refractive  power  is  usually  the  vertical. 

If  one  meridian  is  normal  the  retina  is  at  the  proper  focal 
distance  and  the  eye  is  emmetropic  in  that  meridian,  but 
ametropic  in  the  other.  In  this  case  the  astigmatism  is  simple. 
If  one  meridian  is  emmetropic  and  the  other  myopic,  or  of 
greater  curvature,  then  myopic  astigmatism  is  present  (Am), 
or  if  one  is  emmetropic  and  the  other  hypermetropic,  or  of  less 
curvature,  then  it  is  a  case  of  hyperopic  astigmatism  [Ahy 

In  compound  astigmatism  both  principal  meridians  are 
ametropic,  each  being  myopic,  one  with  a  greater  curvature 
than  the  other,  thus  producing  compound  myopic  astigmatism 
[M-\-Am),  or  both  may  be  hypermetropic,  forming  compound 
hypermetropic  astigmatism  [H-{-Ah).  While  simple  astig- 
matism requires  only  a  cylindrical  glass  for  its  correction, 
compound  astigmatism  requires  a  spherical  glass  combined 
"with  a  cylindrical  glass  to  improve  vision ;  a  convex  spherical 
combined  with  a  convex  cylindrical  in  compound  hypermetropic 
astigmatism,  and  a  concave  spherical  combined  with  a  concave 
cylindrical  in  compound  myopic  astigmatism. 

Mixed  astigmatism  is  that  variety  in  which  one  meridian  is 
myopic  and  the  other  hypermetropic,  and  is  the  most  difficult 
to  determine  accurately,  requiring  for  correction  the  combina- 
tiion  of  a  concave  cylindrical  with  a  convex  cylindrical  glass, 
which  are  generally  ground  at  or  near  right  angles  to  each 
other. 

Symptoms. — The  symptoms  which  arise  from  astigmatism 
are  usually  those  of  indistinct  vision  for  both  near  and  distant 
points.  Objects  often  appear  distorted,  the  distortion  occur- 
ring more  frequently  in  the  direction  of  their  height     The 


ASTIGMATISM— DIAGNOSIS.  95 

announcement  is  frequently  made  that  horizontal  lines  are 
more  distinctly  seen  than  vertical  ones,  or  that  certain  figures 
on  the  dial  of  a  clock  or  watch  are  seen  distinctly,  while  others 
are  much  less  so.  It  is  not  uncommon  for  some  patients 
affected  with  astigmatism  to  be  able  to  overcome  their  defect 
by  means  of  accommodative  effort.  If  this  power  fails,  then 
the  vision  becomes  more  imperfect,  and  they  also  complain  of 
asthenopia  resulting  from  the  overstrained  accommodation. 
Again,  this  tension  of  the  accommodation  results  not  infre- 
quently in  the  production  of  severe  headaches,  which  sometimes 
exist  for  years,  resisting  all  forms  of  treatment,  until  the 
adaptation  of  a  pair  of  cylindrical  glasses  gives  good  vision, 
comfort  to  the  eyes,  and  relief  from  the  headaches,  at  once. 
Other  more  obscure  reflex  nervous  symptoms,  such  as  chorea 
and  neuritis,  have  disappeared  upon  the  correction  of  the 
astigmatism.  Conjunctival  irritation  and  chronic  blepharitis, 
which  resist  treatment  until  proper  glasses  are  prescribed,  are 
also  frequent  accompaniments  of  astigmatism.  It  is  frequently 
associated  with  high  degrees  of  hypermetropia  and  myopia, 
and  causes  asthenopic  headaches  as  well  as  lessens  the  already 
defective  vision. 

Diagnosis. — There  are  many  methods  of  making  a  diagnosis 
of  astigmatism,  and  of  determining  its  degree,  and  all  possess 
^ome  merit  in  individual  cases.  The  most  rapid  way  is  to  test 
the  acuteness  of  vision  by  the  test  type,  and,  if  below  normal, 
then  examine  the  eye  with  the  ophthalmoscope,  and  a  glance 
will  suffice  to  determine  whether  the  case  is  hypermetropic  or 
myopic.  If  it  is  astigmatic  the  optic  disc,  in  the  direct 
method  with  the  erect  image,  will  be  oval  or  elongated,  the 
elongation  corresponding  to  the  meridian  of  greatest  curvature, 
which  is  usually  vertical  or  nearly  so.  The  disc,  or  the  vessels 
upon  certain  portions  of  it,  will  be  more  or  less  indistinct. 
The  retinal  vessels,  however,  form  the  best  tests,  as  they 
emerge  in  a  radial  direction  from  the  disc  and  appear  less 
distinct  in  some  portions  than  in  others,  and  it  is  possible  to 
determine  the  meridians  which  are  defective,  and  whether 
they  are  hypermetropic  or  myopic,  and  possibly  the  degree, 
from  their  appearance. 


»0  DISEASES  AND  INJURIES  OF  THE  EYE. 

In  the  indirect  method  the  disc  is  also  elongated,  but,  the 
image  being  inverted,  the  elongation  is  at  right  angles  to  that 
in  the  direct  method.  If  the  object  lens  of  the  observer  is 
moved  nearer  to  or  further  from  the  eye  there  is  an  apparent 
rotation  of  the  disc,  the  change  being  seen  in  the  long  axis  of 
the  oval,  which,  from  being  vertical,  becomes  horizontal  when 
the  lens  is  held  nearer  to  the  eye  than  its  focal  length,  and  as 
it  is  withdrawn  the  disc  appears  round  and  then  oval  verti- 
cally. The  size  of  the  image  varies  according  to  the  general 
refraction  of  the  eye;  if  emmetropic,  there  is  no  change,  if 
myopic  the  image  increases,  if  hypermetropic,  it  diminishes. 

In  testing  the  eyes  for  astigmatism,  we  proceed  at  once  to 
test  the  eyes  separately  for  myopia  or  hyperopia  with  concave 
or  convex  lenses.  If  the  vision  is  not  made  normal  by  the 
use  of  these  glasses,  or  the  patient  persistently  miscalls  certain 
letters  of  the  test  types,  or  sees  better  when  the  glasses  are 
tilted  before  the  eyes,  then  a  stenopaic  slit,  a  narrow  slit  -^^j  of 
an  inch  wide  in  a  brass  disk,  set  in  a  trial  frame,  is  placed  before 
the  eye,  and  as  the  long  axis  of  the  slit  is  rotated  before  the 
eye,  vision  will  probably  be  improved  in  the  meridian  in  which 
there  is  the  least  defect,  and  concave  or  convex  glasses  in 
front  of  the  slit  will  indicate  the  probable  astigmatic  refraction 
in  that  meridian.  The  slit  is  then  turned  90°  and  a  fresh 
correction  made  if  necessary.  The  astigmatism  may  be  deter- 
mined by  means  of  the  various  test  cards  devised  by  Snellen, 
Carter,  Green,  Pray  and  others,  all  depending  upon  the  fact 
that  when  an  astigmatic  eye  looks  at  a  number  of  lines  drawn 
in  different  directions,  some  appear  more  distinct  than  others. 
One  of  the  simplest  diagrams,  and  as  useful  as  any,  is  that 
presented  in  Fig.  43,  consisting  of  a  fan  of  equal  narrow  black 
rays.  If  a  patient  has  a  myopia  of  3*5  in  the  vertical  meridian, 
and  the  other  meridian  is  normal,  he  will  see  the  horizontal 
lines  distinctly  and  the  others  will  be  somewhat  blurred.  He 
has  then  simple  myopic  astigmatism,  and  a  concave  cylin- 
di'ical  glass  of  -g^g  inch  focus  with  the  axis  vertical  will  make  all 
the  lines  equally  distinct.  If,  again,  he  is  myopic,  say  -j^-,  in 
(the  horizontal  meridian,  the  vertical  lines  will  be  most  distinct 


ASTIGMATISM. 


97 


and  a  concave  cylindrical  glass  of  -^-^  with  the  axis  liorizontal,v J 
will  correct  the  trouble.  If  it  is  a  case  of  simple  hyperopia 
astigmatism  of  the  vertical  meridian,  the  vertical  lines  will 
appear  the  most  distinct.  By  placing  the  proper  convex 
cylinder  before  the  eye,  with  the  axis  horizontal,  the  defect  is 
corrected.  If  the  horizontal  meridian  is  hyperopia  the  hori- 
zontal lines  will  be  the  ones  most  clearly  seen,  and  the  cor- 


FIG,  43. 


recting  glass  will  be  a  convex  cylinder  with  the  axis  vertical. 
The  rays  passing  through  the  horizontal  meridian  will  be 
converged  by  the  lens  and  brought  to  a  focus  upon  the  retina, 
while  the  rays  passing  through  the  vertical  meridian,  not 
being  altered  by  the  glass,  will  still  be  focused  upon  the 
retina. 

In  compound  astigmatism  we  correct  the  myopia  or  hyper- 
opia as  if  no  astigmatism  v/as  present,  and  then  proceed  as 
above  to  correct  the  astigmatism,  using  a  spherico-cylindrical 
glass  for  the  purpose.  The  two  principal  meridians  are  sought 
out  and  tested  separately  by  cylindrical  glasses.  If,  for  in- 
stance, we  have  a  myopia  of  ^^  i^  ^1^®  vertical  meridian,  and 
a  myopia  of  -^^  in  the  horizontal  meridian,  then  a  certain 
amount  of  myopia  is  common  to  both  meridians,  and  amounts 
to  the  difference  between  them,  as  iV~2V~^^o  '  ^^i^re  is  pres- 
ent then  a  myopia  of  ^^.^  which  will  require  a  concave  spherical 
glass  of  gV-  This  will  correct  the  myopia  of  the  vertical 
meridian  and  also  leave  a  myopia  of  -^-^  in  the  horizontal 
7 


08 


DISEASES  AND  INJURIES  OF  THE  EYE. 


meridian  to  be  corrected.  The  glass  then  required  would  be 
a  — 20  s.  combined  witli  (  O  )  — 20  c,  axis  vertical.  If, 
again,  we  find  that  the  vertical  meridian  is  hypermetropic,  say 
■^j,  and  the  horizontal  meridian  -^^  hypermetropic,  then  it  is  a 
case  of  compound  hyperopic  astigmatism  and  the  glasses- 
required  will  be  +30  s.  O  +30  c.  axis  horizontal,  which 
should  make  all  lines  perfectly  clear. 

Cases  of  mixed  astigmatism  are  less  common  than  the  other 
forms  and  much  more  difficult  to  determine,  and  require  a 
great  deal  of  time  and  patience  in  conducting  the  test,  de- 
mands which  are  made  upon  the  surgeon  with  all  cases  of 
astigmatism.  Astigmatic  patients  mean  well,  but  their  ina- 
bility to  define  objects  properly  has  not  prepared  them  to 
answer  correctly,  and  the  result  is  unsatisfactory,  notwith- 
standing their  anxiety  to  be  accurate.  Hence  repeated  exam- 
inations have  to  be  made,  and  results  compared,  before  anything 
satisfactory  has  been  accomplished.  Where  much  difficulty  has 
been  experienced  the  use  of  atropine,  duboisia,  or  homatropine 
should  be  employed  to  paralyze  the  accommodation,  which 
becomes  a  mischievous  factor  in  the  examination.  The  effects 
of  all  these  mydriatics  are  unpleasant  to  the  patient  from  the 
glare  of  light  which  is  admitted  to  the  eye  by  the  dilated 
pupil,  and  the  consequent  loss  of  the  accommodation  prevents 
the  patient  from  reading,  -wTiting  and  all  near  work  for  some 
days  afterwards.  I  prefer  the  hydrobromate  of  homatropine, 
two  grains  to  the  fluid  dram,  in  these  cases,  two  or  three  drops 
producing  complete  paralysis  of  the  acommodation  within  an 
hour.  The  paralysis  lasts  only  about  an  hour,  the  eye  fre- 
quently returning  to  its  normal  condition  in  thirty-six  hours. 
Either  this  or  atropine  should  be  used  in  all  cases  of  myopic 
and  mixed  astigmatism,  as  oftentimes  an  apparent  myopic 
astigmatism  becomes  an  hyperopic  astigmatism  under  the 
influence  of  the  mydriatic  or  even  a  case  of  simple  hyperopia 
or  myopia. 

In  cases  of  mixed  astigmatism,  one  meridian  being  hyper- 
opic and  the  other  myopic,  the  test  cards  which  present  a  full 
circle  of  radiating  lines  are  necessary,  and  the  correction  is 


ASTIGMA  N^M— ANISOMETROPIA. 


99 


made  by  two  cylindrical  glasses  which  are  usually  placed  at 
right  angles  to  each  other  in  the  defective  meridians.  For 
example,  if  the  vertical  meridian  presents  a  myopia  of  y^  and 
the  horizontal  a  hyperopia  of  ^^j^,  then  cylindrical  glasses  are 
prescribed  and  the  prescription  is  written  10  c  p-  16  c  axis 
horizontaL  If  the  defective  meridians  are  other  than  those 
indicated,  then  the  angles  at  which  the  glasses  are  to  be  ground 
are  indicated  on  the  optician's  blank,  which  corresponds  with 
the  graduation  of  the  trial  frames. 

In  regard  to  the  prescription  of  glasses  for  astigmatism,  if 
it  is  simple  the  full  correction  may  be  prescribed  at  once,  and 
may  be  worn  either  for  reading  or  distance,  or  both,  as  the 
individual  cases  may  demand.  If  compound,  the  correction 
of  the  astigmatism  must  be  fully  made,  while  the  use  and 
degree  of  the  glass  for  myopia  or  hyperopia  must  be  deter- 
mined by  the  rules  governing  the  prescription  of  such  glasses 
as  already  described.  If  the  astigmatism  is  mixed,  the  full 
correction  is  to  be  given  for  distance,  and  probably  for  near 
vision  also,  though  the  latter  is  to  be  decided  by  the  comfort 
of  the  patient.  If  there  is  much  amblyopia  the  weakest  glass, 
concave  or  convex,  which  gives  the  best  vision  should  be 
prescribed. 

In  some  cases  different  cylinders  will  be  required  for  near 
vision  than  those  for  distance.  This  is  more  frequently  the 
case  in  simple  astigmatism,  and  a  patient  may  require  a  con- 
vex cylindrical  glass  for  distant,  and  a  concave  cylindrical  in. 
the  same  meridian  for  near  vision. 

When  astigmatics  become  presbyopic  the  cylindrical  correc- 
tion is  to  be  added  to  the  presbyopic  glass. 

ANISOIklETKOPIA. 

This  is  a  term  applied  to  cases  where  the  refraction  of  the 
two  eyes  is  dissimilar.  One  eye  may  be  hyperopic  and  the 
other  emmetropic,  or  one  may  be  emmetropic  and  the  other 
myopic,  in  which  case  the  former  is  used  for  distant  and  the 
latter  for  near  vision.     It  is  not  usual  to  give  glasses  in  these 


100  DISEASES  AND  INJURIES  OF  THE  EYE. 

cases,  as  the  vision  is  monocular,  and  the  glasses  would 
cause  a  difference  in  the  size  of  the  retinal  images,  and  in 
producing  binocular  vision  cause  such  disturbance  in  the 
accommodative  effort  that  the  use  of  the  eyes  would  become 
extremely  irksome.  In  some  cases  the  correction  may  be 
attempted,  but  if  the  glass  is  not  worn  comfortably,  it 
should  be  abandoned.  This  condition  is  a  frequent  cause 
of  strabismus. 


CHAPTER    VI. 
APFECTIONS    OF    THE    MUSCLES. 

ANATOMY       f •  f-  JACKSON,  M.  D. 

QHICAOO. 

The  muscles  of  the  eyeball  are  of  two  classes,  the  intrinsic 
or  internal,  those  of  the  iris  and  ciliary  body,  and  the  extrinsic 
or  external,  those  which  prodjiice  the  movements  of  the  eyeball 
itself.  The  extrinsic  muscles  are  six  in  number,  four  recti 
and  two  oblique  (Fig.  44),  The  recti  or  straight  muscles  arise 
from  a  tendinous  ring  around  the  optic  foramen  and  passing 
forward  are  inserted  into  the  anterior  portion  of  the  sclera  at 
equal  distances  from  each  other  by  expanded  tendons.  These 
tendons  form  a  fibrous  expansion  which  encircles  the  circum- 
ference of  the  globe;  before  insertion  into  the  sclera,  they 
pierce  the  tunica  vaginalis  of  the  globe,  dividing  it  into  an 
anterior  portion,  Tenon's  capsule,  and  a  posterior  part,  the 
capsule  of  Bonnet.  The  insertions  are  not  all  at  the  same 
distance  from  the  corneal  border,  the  insertion  of  the  internal 
rectus  being  nearest  to  the  sclero-comeal  junction,  about  5  mm. 
distant,  while  the  inferior  rectus  joins  the  sclera  at  6  mm., 
the  external  at  7  mm.,  and  the  inferior  at  8  mm.,  from  the 
cornea.  These  varying  distances  are  to  be  remembered  in 
making  a  tenotomy  of  these  muscles.  The  recti  muscles  also 
present  variations  in  their  length,  the  internal  being  shortest 
and  the  external  longest.  Three  of  the  recti,  namely,  the 
superior,  inferior  and  internal,  are  supplied  by  the  3rd  nerve, 
while  the  external  derives  its  nerve  supply  from  the  6th,  or 

101 


102 


DISEASES  AND  INJURIES  OF  THE  EYE. 


abducens.  The  blood  supply  is  derived  from  the  muscular 
branches  of  the  ophthalmic  artery,  which  give  off  in  tlie 
tendons  the  anterior  ciliary  arteries.  The  two  oblique 
muscles,  the  superior  and  inferior,  present  a  different  origin, 
course  and  nerve  supply;  the  superior  oblique  takes  origin 
with  the  recti  muscles,  but  passes  forward  to  the  upper  and 
inner  angle  of  the  orbit,  there  passing  over  a  tendinous 
pulley,  and  turns  outward  and  backward,  and  is  inserted  by 
a  broad,  fan-like  tendon  into  the  outer  side  of  the  ball  behind 
the  equator.      It  is  supplied  by  the  4:th,  or  trochlear,  nerve. 


FIG.  44. 


The  inferior  oblique  arises  from  the  superior  maxillary  bone 
on  the  inner  floor  of  the  orbit,  and  passing  backward,  is 
inserted  on  the  outer  side  of  the  posterior  half  of  the  eyeball 
opposite  the  insertion  of  the  superior  oblique,  with  the 
external  rectus  lying  between  them.  It  is  supplied  by  a 
branch  from  the  3d  nerve.  The  two  oblique  muscles  serve 
to  suspend  the  eyeball  in  the  orbit  as  well  as  to  give  it 
motion. 

The  combined  action  of  the  recti  muscles  results  in  the  re- 
traction of  the  eyeball  into  the  orbit,  while  a  similar  action  of 
the  oblique  muscles  draws  the  globe  forward.  In  the  complex 
movements  of  the  eyeball  the  muscles  are  grouped  together 
in  twos  or  threes  for  the  movements  in  various  directions,  and 


AFFECTIONS  OF  THE  MUSCLES.  10^ 

each  group  during  action  is  opposed  by  a  similar  group.  In 
the  action  of  the  muscles  separately,  the  internal  rectus  turns 
the  e^e  directly  inward  and  the  external  directly  outward. 
The  superior  and  inferior  recti  turn  the  eye  upward  or  down- 
ward, but,  owing  to  the  fact  that  the  origins  of  the  muscles 
are  nearer  the  median  line  of  the  head  than  their  insertions, 
they  also  turn  the  eye  somewhat  inward.  In  order,  then,  to 
turn  the  eye  directly  upward  or  downward  the  action  of  the 
superior  or  inferior  obliq[ue  must  be  added.  The  superior 
oblique  turns  the  eye  downward  and  outward  and  at  the  same 
time  produces  a  partial  rotation  of  it  from  above  downward, 
thus  inclining  the  vertical  meridian  of  the  cornea  inward. 
The  inferior  oblique  rolls  the  eye  upward  and  outward  and 
rotates  it  from  above  downward.  For  looking  in  intermediate 
directions,  as  upward  and  inward,  or  downward  and  inward,  a 
combined  action  of  a  group  of  three  muscles  is  required. 
This  compensatory  action  of  these  additional  muscles  also 
preserves  the  proper  position  of  the  vertical  meridian  of  the 
cornea,  which  would  otherwise  be  drawn  too  far  inward  or 
outward  and  thus  disturb  the  vision.  In  the  normal  action  of 
the  muscles,  the  eye  is  turned  inward  by  the  internal  rectus ; 
outward  by  the  external  rectus;  upward  by  the  combined 
action  of  the  superior  rectus  and  inferior  oblique ;  downward 
by  the  inferior  rectus  and  superior  oblique.  In  the  motion 
of  the  eye  diagonally  upward  and  inward  the  rectus  superior 
acts  in  combination  with  the  rectus  internus,  and  is  further 
controlled  by  the  inferior  oblique  in  directing  the  eye  upward 
and  outward.  The  rectus  superior  and  the  rectus  extemus 
are  assisted  by  the  inferior  oblique,  which  limits  the  action  of 
the  rectus  superior  in  looking  downward  and  inward;  the 
rectus  inferior  and  the  rectus  extemus  by  the  superior  oblique, 
which  controls  the  full  action  of  the  rectus  inferior.  The 
movement  downward  and  outward  is  accomplished  by  the 
rectus  inferior  together  with  the  rectus  extemus  and  superior 
oblique,  the  latter  limiting  the  action  of  the  rectus  inferior. 
From  the  central  line  the  emmetropic  eye  may  move  inward 
4:5  degrees;  outward  50   degrees;  upward   35  degrees;  and 


104:  ■  DISEASES  AND  INJURIES  OF  THE  EYE. 

downward  60  degrees.  These  movements  are  restricted  in 
myopic  eyes  by  the  increase  in  the  antero-posterior  axia  In 
binocular  vision  there  is  an  associated  movement  of  both  eyes, 
the  movement  inward  of  one  being  accompanied  by  an  out- 
ward movement  of  the  other,  the  different  sets  of  muscles 
acting  in  this  way  being  termed  conjugate,  or  yoked  muscles. 
In  the  accommodative  or  converging  movements  of  the  eyes, 
similar  groups  of  muscles  act  in  harmony.  A  disturbance  of 
the  harmony  of  the  action  of  the  muscles  at  once  causes  a 
deviation  from  the  line  of  vision,  and  may  result  from  an 
excess  or  loss  of  power  of  one  or  more  muscles.  This  is 
termed  the  primary  demotion,  and  produces  diplopia  and 
squint.  If  one  of  the  conjugate  muscles  becomes  weakened 
or  paralyzed,  a  greater  effort  becomes  necessary  to  enable  it  to 
attempt  the  motion  of  the  eye.  This  effect,  being  transmitted 
to  its  conjugate  muscle,  produces  there  another  action  and 
consequent  greater  movement.  This  change  in  the  direction 
of  the  other  eye  constitutes  the  secondary  deviation. 

The  muscular  adjustments  must  be  exact,  and  the  motor 
influences  transmitted  just  sufficient  to  produce  that  perfect 
harmony  of  action  necessary  to  direct  the  yellow  spot  of  the 
retina  of  each  eye  upon  the  object,  and  thus  produce  binoc- 
ular vision.  If  the  fovesB  are  not  focused  upon  the  object,' 
or  if  the  images  of  the  object  do  not  fall  upon  corresponding 
portions  of  the  two  retinae,  then  double  vision  or  diplopia 
occurs. 

In  the  normal  eye,  when  the  gaze  is  fixed  upon  an  object 
at  a  distance,  the  visual  axes  appear  parallel.  In  myopic 
eyes  the  axes  may  converge  slightly,  owing  to  the  foveae 
lying  nearer  to  the  axis  of  the  eyeball,  an  apparent  turning 
inward  of  the  eyes.  In  hypermetropia  the  axes  of  the  eyes 
frequently  diverge  slightly;  this  is  not,  however,  divergent 
strabismus,  but  is  due  to  the  fact  that  the  yellow  spot  usually 
lies  farther  from  the  axis  of  the  eyeball  in  hypermetropic 
than  in  emmetropic  or  myopic  persons,  hence,  when  the  optic 
axis  of  the  eye  is  directed  towards  distant  objects,  the  axis 
of  the  eyeball  looks  outward  more  than  in  the  normal  eye, 
giving  rise  to  the  appearance  of  divergent  squint. 


DIPLOPIA. 


105 


DIPLOPIA- 


\F1 


Diplopia,  or  double  vision,  arises  when  the  visual  axes  are 
not  both  directed  upon  the  object  under  examination,  and  is 
almost  always  caused  by  a  deviation  of  the  eyes  or  squint,  but 
this  may  appear  so  slight  as  to  escape  attention  in  many  cases. 
Double  vision  is  sometimes  monocular,  depending  upon 
irregularities  of  the  cornea,  lens,  or  some  disturbance  of  the 
retinal  elements.  It  is,  however,  almost  always  binocular, 
disappearing  when  one  eye  is  covered.  Binocular  diplopia  is 
of  two  kinds,  homonymous  or  direct  and  Tiieronymous  or  crossed. 
Direct  diplopia  will  be  understood  by  an  examination  of 
Fig.  45,  which  shows  the  position  of  the  double  images  In 
convergent  squint.     Here  M  represents  the  macula  lutea,  or 

yellow  spot  of  each  eye, 
O  the  object  looked  at, 
and  V  M  the  visual  axis 
of  the  squinting  eye.  The 
image  of  the  object  O  will 
fall  upon  the  yellow  spot 
M  in  the  left  eye,  and  the 
object  is  seen  in  its  true 
position  and  forms  a  true 
image.  The  visual  axis  of 
the  right  eye  deviates  in- 
ward and  the  image  falls 
upon  a  portion  of  the 
retina  to  the  inner  side  of 
the  yellow  spot,  and  the 
object  will  appear  to  be  at 
F  I,  because  the  part  of 
the  retina  which  now 
receives  the  image  has  been  accustomed  to  receive  objects 
from  this  direction  when  the  eye  was  in  its  normal  position, 
and  hence  mentally  projects  the  image  in  that  direction. 
Thus  two  images  become  visible,  one  in  its  real  position  at 
O  and  another  to  the  right  of  it  at  F  J,  the  latter  being  the 


FIG.  45, 


106 


DISEASES  AND  INJURIES  OF  TEE  EYE. 


false  image.  If  the  left  eye  is  turned  in  and  the  right  eye 
remains  in  the  normal  position,  then  the  false  image  will 
be  to  the  left  of  the  true  image.  In  these  cases  the 
greater  the  deviation  of  the  eye  the  greater  the  squint, 
and  the  wider  apart  are  the  two  images.  The  false  image, 
falling  upon  an  eccentric  portion  of  the  retina,  is  not  usually 
as  distinct  as  the  true  image,  which  is  formed  upon  the  yellow 
spot;  the  greater  the  squint  the  less  distinct  will  the  false 
image  be,  as  it  is  then  formed  still  further  from  the  central 
portion  of  the  retina. 

In  the  second  form,  or  crossed  diplopia,  the  images  cross 
each  other  as  shown  in  Fig.  46.  Here,  a  divergent  squint  is 
present,  the  left  eye  being  fixed  upon  the  object  at  O,  and  the 

.  right  eye  deviating  out- 
I  ward  from  its  fellow.  The 
object  at  O  is  perceived  in 
its  proper  position  by  the 
left  eye,  and  a  true  image 
is  formed  upon  the  macula 
lutea  at  M.  The  right 
eye,  however,  being  turned 
outward,  the  macula  is  di- 
rected toward  V,  and  the 
image  of  the  object  at  O 
falls  upon  a  portion  of  the 
retina  to  the  outer  side  o£ 
the  macula,  and  is  ment- 
ally projected  to  the  left 
of  O  at  F  I,  and  the  false 
image  is  thus  seen  to  the 
left  of  the  true  image, 
and  they  appear  crossed.  If  the  squinting  eye  is  turned 
upward,  the  image  falls  upon  the  retina  above  the  macula 
and  appears  below  the  true  image.  If  the  eye  squints 
downward,  then  the  false  image  is  projected  above  the 
true  image  as  seen  by  the  other  eye.  The  false  image 
formed  in  cases  of  squint,  if    sufficiently  well  defined,   will 


FIG.  46. 


DIPLOPIA— PARALYSIS  OF  OCULAR  MUSCLES. 


107 


be  perceived,  and  the  images  received  by  the  two  eyes, 
being  superimposed  in  the  sensorium,  will  cause  a  con- 
fusion, of  the  vision,  and  vertigo,  nausea  or  pain  results.  In 
many  cases,  particularly  if  the  deviation  which  causes  the 
diplopia  is  great,  or  exists  for  a  long  time,  only  one  image  is 
regarded,  the  perception  of  the  other  being  neglected  or 
suppressed;  the  suppressed  image  always  being  that  of  the 
squinting  eye.  To  detect  the  presence  and  position  of  the 
double  images  in  diplopia,  the  patient  should  be  taken  into  a 
dark  room,  the  head  fixed  or  held  in  one  position  without 
moving,  and  a  colored  glass,  blue  or  red,  placed  before  one 
eye.  A  lighted  candle  is  then  held  eight  or  ten  feet  distant 
and  moved  to  the  right,  left,  above,  below,  and  other  inter- 
mediate portions  of  the  field,  and  the  patient  asked  which  is 
the  colored  flame.  The  position  of  the  images,  as  described 
by  the  patient,  are  then  noted  upon  a  slip  of  paper,  but  if  the 
deviation  is  very  great,  and,  particularly,  if  the  action  of  the 
internal  rectus  is  poor,  the  false  image  becomes  indistinct,  and 
difficulty  is  experienced  in  getting  proper  replies  from  the 
patient;  in  such  case  it  is  better  to  place  the  colored  glass 
before  the  sound  eye.  The  greater  the  distance  of  the  candle 
and  the  farther  it  is  moved  in  the  direction  of  the  affected 
muscle,  the  more  widely  separated  the  images  become.  For 
all  practical  purposes  a  roll  of  white  paper  one  foot  long,  held 
perpendicularly  ten  feet  distant  from  the  patient  in  a  lighted 
room,  will  suffice ;  one  eye  should  be  covered  with  a  red  glass 
and  the  height,  lateral  separation  and  apparent  distances 
recorded  as  before. 

PARALYSIS  OF  THE  OCULAR  MUSCLES. 

In  rare  cases  all  of  the  muscles  may  be  paralyzed,  the  third, 
fourth  and  sixth  nerves  all  participating.  In  the  majority  of 
cases  single  muscles,  or  those  supplied  by  one  nerve,  are  alone 
affected.  In  many  cases  the  condition  may  be  only  one  of 
paresis,  which  may  follow  or  precede  the  paralysis.  The 
affection  is  seldom  symmetrical,  and  in  rare  cases  where  it 


108 


DISEASES  AND  INJURIES  OF  THE  EYE. 


does  occur,  the  cause  is  always  intra-cranial  or  spinal.  Where 
it  is  monolateral  the  lesion  may  be  either  local  or  central.  In 
most  of  the  cases  of  uncomplicated  paralysis  of  the  ocular 
muscles,  there  is  nothing  in  the  state,  either  of  the  eye  or 
orbit,  to  enable  one  to  locate  the  cause  either  in  the  orbit  or 
cranium.  The  probable  location  of  the  lesion,  in  either  case, 
miay  be  determined  by  noting  whether  all  the  muscles  supplied 
\>j  the  third  nerve  are  affected  or  only  one  of  them,  or  whether 
the  fourth  or  sixth  nerves  are  alone  affected,  while  bearing  in 
mind  their  origin  and  course  in  the  brain  and  orbit. 

Causes. — Rheumatism,  syphilis,  localized  periostitis,  inflam- 
mation of  the  nerve  sheath,  injuries,  basilar  meningitis,  tumors 
of  any  kind,  hemorrhage  and  central  nerve  degenerations,  are 
all  active  causes  in  the  production  of  paralysis  of  the  ocular 
muscles. 

Symptoms. — Loss  of  mdbilUy  in  the  direction  of  the  para- 
lyzed muscle  is,  objectively,  the  most  ^prominent  symptom.  If 
the  patient  is  directed  to  look  at  an  object,  as  the  finger,  held 
Isefore  the  eye,  and  follow  its  movements  wdthout  changing 
the  position  of  the  head,  the  affected  eye  is  found  to  fail  in  its 
movement  in  the  direction  of  th«  affected  muscle  in  proportion 
to  its  weakness.  Subjectively,  diplopia  is  complained  of,  and 
this  is  often  present  before  the  loss  of  motion  can  be  detected. 
The  position  of  the  images,  whether  homonymous  or  crossed, 
and  above  or  below,  will  give  a  clue  to  the  muscles  affected. 
With  the  diplopia  there  is  often  false  projection  of  the  field  of 
vision,  the  image  falling  upon  an  eccentric  portion  of  the 
retina,  the  patient  is  unable  to  determine  the  exact  distance, 
and  hence  experiences  difficulty  in  walking,  or  reaching  for 
objects,  and  this  not  infrequently  results  in  nausea  and  vertigo, 
or  other  cerebral  symptoms.  The  head  is  usually  inclined  in 
the  direction  of  the  affected  muscle  so  as  to  lessen  the  diplopia 
l)y  favoring  it,  or  the  eye  is  closed  to  obviate  double  images. 
Undue  prominence  of  the  eye  occurs  in  paralysis  of  all  the 
recti,  and  is  accompanied  by  a  drooping  of  the  lid  (ptosis). 

'■  Squint  is  always  a  symptom  of  paralysis,  where  the  affection 
has  existed  for  some  time,  and  is  due  to  the  contraction  of  the 


DIAGNOSIS  OF  PARALYTIC  AFFECTIONS.  109 

opposing  muscle,  the  eye  being  permaiiently  fixed  in  the 
direction  opposite  to  the  paralyzed  muscle;  and  when  thia 
occurs,  the  vision  of  the  affected  eye  rapidly  deteriorates  from 
the  suppression  of  the  image,  and  amblyopia  from  non-use 
results.  In  paralytic  squint,  if  the  hand  is  placed  over  the 
sound  eye  in  such  a  manner  that  its  movements  may  be 
observed,  while  the  affected  eye  is  directed  upon  the  object 
held  before  it  and  moved  in  the  direction  of  the  paralyzed 
muscle,  the  eye  will  attempt  to  follow  it.  The  effort  thus 
made  is  transmitted  to  tho  conjugate  muscle  of  the  other  eye, 
and  a  motion  of  the  sound  eye  will  occur,  which  will  carry  it 
so  far  as  to  produce  a  squint  which  is  greater  than  that  of  the 
affected  eye ;  this  is  termed  the  secondary  deviation  or  squint. 
In  paralytic  squint  this  secondary  deviation  is  always  greater 
than  the  primary  deviation  of  the  affected  eye. 

DIAGNOSIS  OF  PARALYTIC  AFFECTIONS  OF  DIFFERENT  MUSCLES. 

Kectus  Inteenus. — While  the  isolated  paralysis  of  the 
branches  of  the  motor  oculi  are  not  common,  the  branch  sup- 
plying the  internal  rectus  is  more  fivquently  affected  than  the 
others.  The  eye  cannot  be  turned  inward,  and  divergent 
squint  may  result.  Diplopia  appears,  and  the  images  are 
crossed  vertically  and  on  the  same  level,  and  become  wider 
apart;  or  the  false  image  disappears  when  the  object  is  carried 
to  the  opposite  side  of  the  affected  muscle.  The  patient  tuma 
the  head  toward  the  direction  opposite  to  the  paralyzed  muscle 
to  overcome  the  diplopia  as  far  as  possible. 

Rectus  Superior. — If  the  nerve  supply  of  the  superior 
rectus  is  deficient  the  patient  finds  difficulty  in  ascending 
stairs,  as  the  false  image  is  projected  above  the  true  image, 
diverges  from  it  at  the  top  and  is  slightly  crossed,  and  a  down- 
ward squint  results.  As  the  superior  division  of  the  third 
nerve  also  supplies  the  levator  palpebrae,  ptosis  is  almost 
always  a  complication.  To  correct  the  diplopia  the  head  is 
directed  upward  and  backward. 

Rectus  Inferior. — If  the  rectus  inferior  is  paralyzed,  the 


110  DISEASES  AND  INJURIES  OF  THE  EYE. 

eye  cannot  be  turned  downward,  although  there  is  an  oscillating 
movement  in  that  direction  resulting  from  the  action  of  the 
superior  oblique.  Tho  diplopia  is  somewhat  crossed,  the  false 
image  is  below,  but  converges  at  the  top  and  appears  closer  to 
the  eye  than  the  true  image.  Difl&culty  is  experienced  in 
going  down  stairs  or  in  walking,  and  to  overcome  the  defect 
the  head  is  carried  forward  and  downward.  If  squint  results 
the  eye  is  turned  upward. 

Inferior  Oblique. — The  eye  cannot  be  rotated  upward  and 
outward,  and  when  an  attempt  is  made  to  look  upward  the 
superior  rectus  carries  the  eye  upward  and  inward.  It  rarely, 
if  ever,  occurs  without  some  of  the  other  muscles  being 
involved.  The  double  images  are  crossed  and  appear  one 
above  the  other  and  the  false  image  is  inclined  towards  the 
other  at  the  bottom.  If  the  eye  is  moved  inward  the  difference 
in  the  height  increases,  and  when  turned  outward,  the  inclina- 
tion of  the  images  becomes  more  marked. 

Paralysis  of  the  Third  Nerve. — In  complete  paralysis  of 
the  third  nerve,  the  uppei  lid  droops  over  the  ball  (ptosis)  and 
the  eye  is  turned  outward  and  cannot  move  in  any  direction 
except  partly  downward.  The  pupil  is  dilated,  the  accommo- 
dation paralyzed  and  the  eyeball  is  more  prominent  from  the 
loss  of  the  normal  tension  of  the  recti.  When  all  the  muscles 
supplied  by  the  third  ners^e  are  affected,  the  lesion  exists 
either  at  the  apex  of  the  orbit  or  in  the  cranium.  If  only  one 
or  two  of  these  branches  are  paralyzed  the  cause  is  situated  in 
the  orbit 

Superior  Oblique. — Here  there  is  homonymous  diplopia 
in  the  lower  half  of  the  visual  field.  The  eye  lags  when  the 
vision  is  directed  downward,  the  ball  moving  downward  and 
inward.  The  double  images  separate  more  widely  and  the 
upper  ends  are  inclined  toward  each  other.  The  patient  finds 
difficulty  in  descending  stairs,  and  endeavors  to  correct  it  by 
carrying  the  head  forward  and  to  the  opposite  side  of  the  eye 
affected. 

External  Rectus. — The  paralysis  of  the  abducens  is  more 
frequent  than  the  other  forms,  and  causes,  as  it  is  complete  or 


PARALYTIC  AFFECTIONS— TREATMENT.  HI 

partial,  more  or  less  inability  to  turn  the  eye  beyond  the 
middle  line.  The  diplopia  is  homonymous  and  is  more 
marked  when  the  object  is  moved  to  the  affected  side,  lessening 
and  disappearing  as  the  eye  is  turned  inward.  The  images 
are  parallel,  perpendicular  and  on  the  same  level,  but  when 
the  object  is  moved  diagonally  upward  and  outward  the  false 
image  is  lower  than  the  true,  diverging  slightly  at  the  top,  and 
when  moved  downward  is  higher,  inclining  slightly  at  the  top, 
and  appears  nearer  to  the  patient,  while  convergent  squint 
generally  results.  The  patient  endeavors  to  overcome  the 
faulty  action  of  the  muscle  by  turning  the  head  in  the  oppo- 
site direction  to  the  affected  eye. 

TREATMENT. 

When  the  paralysis  is  effected  by  rheumatic  or  syphilitic 
causes  the  prognosis  is  usually  very  favorable,  but  when  arising 
from  intra-cranial  or  spinal  disease,  recovery  is  less  likely  to 
occur.  If  the  recovery  is  not  complete,  paralytic  squint  and 
diplopia  usually  remain.  The  treatment  must  be  addressed  to 
the  probable  cause,  and  to  discover  this  requires  a  very  careful 
inquiry  into  the  history,  symptoms  and  condition  of  the 
patient.  The  ophthalmoscope  may  prove  an  aid  by  revealing 
the  presence  of  an  optic  neuritis  dependent  upon  intra-cranial 
or  orbital  specific  lesion. 

Faradaism  and  galvanism  may  prove  beneficial  and  in  some 
cases  effect  a  cure  alone.  The  galvanic  current  appears  more 
useful  than  the  faradic,  and  the  application  should  last  but  a 
minute,  and  be  made  daily.  A  small  bulb  electrode,  covered 
with  wet  chamois  skin,  may  be  applied  to  the  conjunctiva 
directly  over  the  insertion  of  the  muscle,  or  in  the  same  posi- 
tion upon  the  closed  eyelid.  The  other  pole  may  be  applied 
to  the  occiput  or  to  the  mastoid.  Usually,  the  negative  elec- 
trode should  be  applied  to  the  eye,  but  some  cases  will  be  more 
benefitted  by  the  reverse  current.  The  strength  of  the  current 
must  not  be  sufiicient  to  cause  vertigo,  nor  the  electrodes  sud- 
denly lifted  after  ha^-ing  been  applied  to  the  head.     A  small 


112  DISEASES  AND  INJURIES  OF  THE  EYE. 

percentage  of  cases  will  be  improved  by  the  use  of  tlie  f  aradic 
or  galvanic  current  applied  to  the  angle  of  the  jaw  and  to  the 
Bupra-orbital  region  and  side  of  the  nose;  the  result  accom- 
plished being  due  to  the  reflex  irritation  through  the  fifth 
nerve. 

Prisms  set  in  spectacle  frames  may  correct  the  double  vision, 
but  practically  prove  of  little  service,  as  the  prism  can  only 
relieve  a  certain  amount  of  the  diplopia,  which  varies  with  the 
direction  of  the  vision.  To  determine  the  degree  of  the  prism 
required,  the  patient  is  directed  to  regard  a  lighted  candle  or 
gas-jet,  ten  or  twelve  feet  distant,  when  he  will  see  two  images 
of  the  light.  The  weakest  prism,  base  in  or  out  according  to 
the  muscle  affected,  which  will  unite  the  images  will  be  the 
one  required,  but  if  it  is  over  eight  or  ten  degrees,  then  the 
prismatic  glasses  become  too  bungling  for  comfortable  wear 
and  the  effect  may  be  divided  between  the  two  eyes,  and  the 
affected  eye  given  slightly  more  than  one-half  the  whole 
degree.  After  a  week  or  two  it  may  be  found  that  weaker 
prisms  will  enable  him  to  fix  the  images,  and  the  glasses 
should  be  accordingly  changed  until  very  weak  prisms,  or 
none,  are  required. 

In  addition  to  the  aids  already  recommended,  medical 
treatment  will  prove  useful  in  many  cases  when  the  remedies 
are  selected  according  to  the  cause  and  symptoms. 

Aconite. — This  remedy  suits  those  cases  of  partial  paralysis 
arising  from  exposure  to  cold  winds  or  draughts. 

Argentum  nitricum. — Cases  of  paralysis  of  the  internal 
rectus  have  been  relieved  by  this  remedy. 

Arnica. — Commonly  indicated  in  those  cases  of  temporary 
paralysis  resulting  from  injury. 

Causiicum. — Paralysis  of  the  muscles  resulting  from  ex- 
posure to  cold,  particularly  of  the  external  rectus,  with  some 
involvment  of  the  third  nerve,  and  may  be  useful  in  a 
general  peripheral  paralysis  of  any  of  the  ocular  muscles. 

Chelidonium. — Paralysis  of  the  right  external  rectus. 

Cuprum  aceticum. — Paresis  or  paralysis  of  the  external 
rectus.. 


MUSCULAR  ASTHENOPIA.  113 

Euphrasia. — Paralysis  of  tlie  branches  of  the  third  nerve 
arising  from  exposure  to  cold  or  wet,  the  other  symptoms  of 
Euphrasia  being  present. 

Gelsemium. — Extremely  valuable  in  those  cases  following 
diphtheria,  the  action  upon  the  external  rectus  being  more 
marked. 

Kali  iodatum. — Particularly  indicated  in  paralysis  of  the 
muscles  arising  from  syphilitic  causes,  more  commonly  the 
paralysis  of  the  rectus  externus. 

Mercurius  iod. — Paralysis  of  the  third  nerve  and  its  branches 
in  cases  arising  from  syphilis. 

NiLX  vomica. — Paralysis  or  paresis  of  the  ocular  muscles, 
accompanying  gastric  disturbances,  and  if  aggravated  by 
tobacco  or  stimulants. 

Phosphorus. — Paralysis  of  the  muscles  arising  from  ex- 
cesses, and  accompanied  by  general  loss  of  muscular  tone. 

Rhus  tox. — Paralysis  of  the  muscles  arising  from  rheuma- 
tism, exposure  to  cold  and  wet. 

Senega. — This  remedy  has  been  reported  as  curing  loss  of 
power  of  the  left  superior  rectus  and  other  branches  of  the 
occulo-motorius,  and  is  beneficial  in  paralysis  of  the  superior 
oblique. 

Other  remedies,  as  Aurum,  Hyoscyamus,  Conium,  Morph. 
and  Sulphur  may  be  used  with  advantage. 

Paralytic  squint,  arising  as  it  does  from  the  secondary  con- 
traction of  the  opposing  muscle,  requires  operative  measures 
for  its  relief  when  the  recovery  of  the  paralyzed  muscle  is 
hopeless.  For  its  correction,  tenotomy  of  the  contracting 
muscle  should  be  made  .and  at  the  same  time  the  insertion  of 
the  paralyzed  muscle  advanced,  as  will  be  described  for  certain 
cases  of  strabismus. 

MUSCULAR    ASTHENOPIA 

Paresis    of    the    muscles,    muscular    weakness    or    insuflfi- 
ciency,  is  not  usually  great  enough  to  produce  any  deviation 
of  the  eyes  or  squint,  but  manifests  itself  in  pain  or  fatigue 
8 


114 


DISEASES  AND  INJURIES  OF  THE  EYE. 


after  use  of  the  muscles  involved.  The  muscles  most  com, 
monly  affected  are  the  internal  and  external  recti.  In  rare 
cases  the  insufficiency  may  be  traced  to  the  superior  oblique, 
and  to  the  superior  and  inferior  recti. 

Causes. — Refractive  errors  are  usually  the  productive  causes 
of  muscular  asthenopia;  myopia  and  astigmatism  producing 
weakness  of  the  internal  rectus,  and  hypermetropia  of  the 
external  rectus.  The  other  causes  productive  of  muscular 
asthenopia  in  either  emmetropia  or  ametropia,  are,  fatigue  of 
the  eyes  from  over-work  on  fine  objects,  as  in  flower  or  china 
painting,  embroidery,  etc. ;  general  neurasthenia,  when  the 
muscular  insufficiency  may  accompany  or  follow  the  general 
condition;  convalescence  after  continued  fevers  or  the  exan- 
themata, particularly  reading  in  a  prone  position;  uterine 
diseases;  chorea;  excesses  of  any  kind;  derangement  of  the 
digestive  organs;  insufficient  food;  or,  the  muscular  weakness 
may  be  congenital. 

Si'MPTOMS. — The  symptoms  are  those  of  fatigue  from  use 
of  the  eye.  There  is  pain  which  may  be  referred  to  the  eye- 
ball, forehead,  temple,  or  vertex,  producing  what  may  well  be 
termed  asthenopic  headaches.  The  pain  is  temporarily 
relieved  by  pressure  upon  the  closed  eyes  and  momentary 
rest  Dizziness  and  nausea  are  not  infrequent  accompani- 
ments of  the  condition.  After  reading  for  a  time  the  letters 
may  appear  to  dance  or  swim  before  the  eyes,  producing  a 
blur,  which  is  similar  to  that  occurring  in  weakness  of  the 
accommodation.        "^  hjJv*^. 

Insufficiency  of  the  internal  recti  is  more  common  than 
the  other  forms,  and  is  produced  by  the  lighter  degrees  of 
myopia,  the  strain  upon  the  internal  recti  being  relieved  by 
the  divergence  of  the  eyes  in  the  higher  degrees.  It  appears, 
however,  with  almost  equal  frequency  in  emmetropic,  rarely  in 
hypermetropic  eyes,  from  the  causes  already  enumerated. 

Insufficiency  of  the  external  recti  occurs  with  much  less 
frequency,  and  hypermetropia  forms  the  most  common  cause. 
The  ciliary  muscle  not  infrequently  participates  in  the  weak- 
ness, when  the  case  becomes  complicated  with  accommodative 
asthenopia  or  ciliary  spasm,      t^^j  a_ 


v-«-^ 


*^ 


'V 


MUSCULAR  ASTHENOPIA— TREATMENT.  115 

Diagnosis. — The  diagnosis  is  readily  made  by  directing  the 
patient  to  look  at  the  finger  or  pencil,  held  eight  or  ten  inches 
from  the  eye  in  the  median  line.  One  eye  is  then  covered  by 
a  card  in  such  a  manner  as  to  shut  out  the  eye  from  the 
object  of  fixation,  but  at  the  same  time  to  enable  the 
observer  to  see  if  it  deviates  outward.  A  more  delicate 
test  is  that  of  Von  Graefe  where  a  prism  of  eight  or 
ten  degrees  is  placed  with  the  base  up  or  down  before 
the  eye,  and  the  patient  directed  to  look  at  a  black  dot 
on  a  vertical  line,  as  in  Fig.  47,  held  at  the  usual  reading 
distance.  If  the  relative  strength  of  the  muscles  is 
normal,  two  dots  will  be  seen  on  the  same  line,  but  if 
two  lines  appear  with  a  dot  upon  each,  the  lateral  sepa- 
ration of  the  lines  measures  the  insufficiency,  or  it  may 
be  measured  more  accurately  by  the  prism,  with  the  base 
turned  inward  or  outward,  which  is  sufficient  to  fuse  the 
images  of  the  two  lines;  placing  a  colored  glass  before 
one  eye  will  determine  whether  the  images  thus  formed 
are  homonymous,  as  in  affections  of  the  internal  recti,  or 
crossed,  as  with  insufficiency  of  the  external  recti. 

Treatment. — The  treatment  consists  principally  in  the 
correction  of  the  refractive  error,  the  methodical  exercise 
of  the  eyes  for  increasing  periods  daily,  and  the  use  of 
such  remedies  as  have  an  action  upon  the  ocular  muscles. 
This  is  usually  all  that  is  needed  to  complete  the  cure; 
where  myopia  is  the  cause,  the  glasses  may  be  slightly 
decentred,  or  prisms  with  the  base  inward  combined,  or 
weaker  glasses  than  those  required  for  distant  vision 
prescribed.  If  hypermetropia  is  the  active  cause,  the 
glasses  to  correct  the  refraction  may  be  required  to  be 
worn  constantly,  or  combined  with  prisms,  or  decentred, 
FIG.  47.  or  set  nearer  together.  Slight  degrees  of  astigmatism 
which  are  not  sufficient  to  impair  the  visual  acuity  may  be 
required  to  be  corrected  by  glasses  which  are  to  be  worn 
constantly.  The  galvanic  or  faradic  current,  often  improves 
the  muscular  tone  and  may  be  applied  for  two  or  three 
minutes  daily,  one  pole  over  the  closed  eyelids  and  the  other 


116  DISEASES  AND  INJURIES  OF  THE  EYE. 

upon  the  temple  or  nape  of  the  neck.  Treatment  which  tend» 
to  improve  the  general  vigor  of  the  patient  and  remove  any- 
constitutional  derangement,  improve  digestion,  and  increase^ 
the  general  muscular  tone,  is  indicated. 

For  the  methodical  exercise  of  the  eyes,  the  patient  is  to  read 
in  the  morning,  after  breakfast,  for  two,  three  or  five  minutes 
the  first  day,  and  the  length  of  the  reading  period  increased 
by  one  or  two  minutes  a  day  until  half  an  hour,  or  an  hour  is- 
reached;  no  additional  increase  is  now  made  for  several  days, 
then  another  sitting  may  be  begun  for  increasing  periods. 
The  sittings  should  always  stop  short  of  fatigue,  and  it  may  b© 
necessary  to  return  to  a  less  number  of  minutes  until  the  first 
point  of  fatigue  is  again  passed  comfortably. 

The  gymnastic  exercise  of  the  muscles  by  the  use  of  prisms- 
of  varying  degrees,  the  bases  of  which  are  turned  alternately 
in  or  out,  may  be  useful  in  a  few  cases,  but  the  results  are  not 
as  favorable  as  they  would  seem  likely  to  be.  The  patient 
takes  the  prisms  of  five,  ten,  or  fifteen  degrees,  placing  the' 
bases  in  or  out  according  as  the  weakness  is  of  the  internal  or 
external  recti  muscles,  and  tries  to  fuse  the  images  of  a  gas- 
jet  fifteen  or  twenty  feet  distant.  Still  stronger  prisms  are 
used  the  next  day,  and  the  exercise  continued  until  a  satis- 
factory increase  in  the  power  of  the  muscle  has  taken  place. 
I  have  known  patients  by  daily  exercise  to  finally  overcome= 
prisms  amounting  to  sixty  degrees  in  adduction  without 
improvement  in  the  symptoms  of  asthenopia,  although  there 
was  a  constantly  increasing  improvement  in  the  adductive 
power  of  the  internal  recti.  Much  relief  is  experienced  in 
asthenopia  by  the  prescription  of  the  proper  medicinal  remedy 
according  to  the  following  indications: 

Aconite. — Asthenopia  from  over-use  of  the  eyes ;  lids  spas- 
modically closed  with  a  heavy  feeling  in  them.  Hot  and  dry- 
feeling  of  the  eyes  after  use,  relief  from  cold  applications. 

Agaricus. — Twitching  of  the  lids,  jerking  or  sensation  of 
jerking  in  the  eyeballs. 

Argentum  niiriciim.  —  Weakness  of  the  internal  recti, 
together  with  weakness  of  the  accommodation  dependent  upon 
hyperopia ;  blurring  and  dancing  of  the  letters. 


ASTHENOPIA— REMEDIES.  IIT 

Duhoisia. — External  recti  weak,  with  weakness  of  the 
accommodation,  and  hot  dry  feeling  of  eyes  from  reading. 

Calcarea  carb. — Pains  after  using  the  eyes;  pains  referred 
usually  to  the  lids;  sticking  pains  while  using  the  eyes  for 
€lose  work ;  eyes  feel  better  from  applications  of  hot  water. 

Gelsemium. — Asthenopia  with  weakness  of  the  external  recti, 
often  associated  with  spasmodic  condition  of  the  internal  recti. 

Jdborandi. —  Asthenopia,  with  symptoms  which  are  really 
dependent  upon  irritability  of  the  ciliary  muscle,  and  in  those 
cases  of  muscular  asthenopia  arising  from  reflex  irritation  of 
the  uterus. 

Kalmia  Za^.— The  muscles,  either  the  internal  or  external 
recti  feel  stiff,  eyeballs  feel  stiff. 

Lilium  iigrinum. — Burning,  smarting,  and  heat  in  the  eyes; 
relief  in  the  open  air. 

Mercurialis  pcren.— Dryness  of  the  eyes  and  heaviness  of 
the  lids;  mist  before  the  eyes;  burning  pain  in  the  eyes  and 
upon  reading. 

Natrum  muriaUcum. — More  frequently  indicated  than  other 
remedies.  Refractive  error  may  or  may  not  be  present.  Par- 
ticularly suits  those  cases  caused  by  over-use,  or  too  close 
application  for  near  objects;  the  vision  blurs  and  the  letters 
run  together  upon  using  the  eyes  for  reading.  Weakness  of  the 
internal  recti  is  oftentimes  very  marked ;  the  muscles  feel  stiff 
and  drawn,  and  ache  on  using  the  eyes  in  any  direction ;  pain 
in  the  eyes  on  looking  down ;  suits  some  cases  of  asthenopia, 
with  headache,  burning,  smarting,  itching  and  heat  with  a 
Tariety  of  other  sensations. 

Phosphorus. — Deficiency  of  sight,  with  pain  and  stiffness  in 
the  eyeball;  light  aggravates  so  the  patient  is  better  in  the 
twilight;  symptoms  of  retinal  irritation  accompany. 

Physostigma.  — Weakness  of  internal  recti.  Fatigue  and 
twitching  of  the  lids  from  reading. 

Rhododendron. — Insufficiency  of  the  internal  recti  muscles 
with  darting  pains  through  the  eyes  and  head,  usually  worse 
Ijefore  a  storm. 

Sepia. — Some  cases  of  muscular  insufficiency  arising  from 


118  DISEASES  AND  INJURIES  OF  THE  EYE. 

reflex  irritation  of  the  uterus ;  smarting  of  the  eyes ;  aggravation 
of  the  symptoms  in  the  morning  and  evening. 

Spigelia. — If  accompanied  by  sharp  sticking  pains  in  the 
eye  and  around  it,  extending  back  into  the  head. 

In  addition  to  these  many  other  remedies  may  be  indicated 
by  their  constitutional  symptoms,  as  Crocus,  Cimicif.,  Ignatia, 
Ledum,  Lith.  carb,  Macrotin,  Nux  vomica,  Phos.  acid,  Pulsa- 
tilla, Santonine  and  Sulphur. 

STEABIS^rUS. 

Strabismus,  or  squint  arising  from  paralysis  of  the  ocular 
muscles  has  already  been  considered,  but  there  is  another  form 
of  squint  -which  is  dependent  upon  the  contraction  of  certain 
of  the  ocular  muscles,  and  is  termed  concomitant  strabismus^ 
or  simple  squint.  In  the  paralytic  variety  there  is  loss  of 
mobility  of  the  eye  in  some  directions,  but  with  concomitant 
squint,  the  eyes  when  tested  separately,  are  freely  movable  in 
any  direction,  although  there  is  an  inability  to  fix  both  eyes 
upon  an  object  at  the  same  time. 

Of  strabismus  we  have  four  varieties,  convergent  or  internal, 
divergent  or  external,  sursumvergent  or  upward,  and  deorsum- 
vergent  or  downward. 

CONVERGENT    STRABISMUS. 

The  most  common  and  readily  treated  is  convergent  strabis- 
mus, which  depends  upon  a  shortening  of  the  internal  recti 
muscles  and  generally  commences  in  infancy.  The  visual  axes 
cross  in  front  of  the  object,  and  there  is  diplopia  in  the  begin- 
ning, but  the  child  soon  learns  to  suppress  one  image,  and 
from  this  suppression  of  the  image  the  squinting  eye  soon 
becomes  amblyopic  from  want  of  use.  In  most  cases  only  one 
eye  is  used  for  vision  and  the  other  is  turned  inward  towards 
the  nose.  In  some  cases  one  eye  is  used  for  a  time  and  then 
the  other;  this  constitutes  alternate  squint  and  in  this  case  the 
vision  is  usually  retained  in  both  eyes.  If  the  squint  is  not 
constant,    but   appears    only  at  times,  it   is    termed  peinodic 


CONVERGENT  STRABISMUS.  119 

squint,  but,  after  an  interval  of  weeks  or  months,  it  becomes 
permanent.  The  amount  of  squint  is  generally  greatest  during 
near  vision,  and  often  disappears  entirely  when  distant  objects 
are  looked  at. 

Causes. — The  causes  are  variously  stated  by  the  laity  as 
arising  from  convulsions,  whooping  cough,  measles,  scarlatina, 
fright,  falls,  and  imitation  of  other  squinting  children.  Some 
of  these  causes  are  undoubtedly  the  excitants  in  some  cases, 
by  producing  a  weakened  condition,  or  paralysis  of  the  exter- 
nal recti,  which  results  in  a  preponderance  of  power  of  the 
internal  recti.  The  common  cause  of  convergent  strabismus  is, 
however,  due  to  hypermetropia.  When  we  look  at  near  objects 
we  do  two  things,  we  converge  the  optic  axes  by  using  the 
internal  recti,  and  then  accommodate  for  a  near  point,  conver- 
gence and  accommodation  being  physiologically  connected.  In 
hypermetropia  accommodation  is  necessary  for  distant  objects, 
and  convergence,  or  a  tendency  to  convergence,  results.  If 
binocular  vision  exists,  the  hypermetrope  endeavors  to  form 
a  single  image,  and  consequently  gives  up  the  attempt  to  see 
at  a  distance,  which  would  require  the  full  exercise  of  the 
accommodation,  and  result  in  a  convergence  of  the  axes  and 
in  the  production  of  diplopia.  If  the  vision  is  more  defective 
in  one  eye,  the  image  produced  upon  the  retina  being  less 
distinct  than  the  other  is  disregarded,  and  convergence  in 
accord  with  the  full  amount  of  accommodation  is  allowed,  and, 
while  the  better  eye  is  directed  upon  the  object,  the  other  is 
strongly  turned  inward.  In  these  cases  the  internal  recti 
become,  from  constant  exercise,  more  highly  developed  than 
the  external,  and,  having  once  overcome  the  latter,  permanent 
contraction  results.  Convergent  strabismus  appears  during 
tlie  first  years  following  infancy,  the  majority  of  cases  occur- 
ring between  two  and  five  years  of  age,  at  the  time  when  the 
child  is  just  beginning  to  use  the  eyes  for  observation  of  its 
toys,  picture  books,  or  make  its  first  attempts  at  reading.  It 
may  be  only  occasionally  observed;  later,  it  becomes  alter- 
nating, and  finally  permanent. 

The    vision    of    the    excluded    or    squinting    eye    rapidly 


120  DISEASES  AND  INJURIES  OF  THE  EYE. 

deteriorates  from  two  causes;  that  most  commonly  given  is 
amblyopia,  or  poor  vision,  from  want  of  proper  exercise  of  the 
region  of  the  yellow  spot  at  a  time  when  the  eye  is  still 
developing ;  secondly,  compression  of  the  eyeball  by  the  tension 
of  the  rectus  externus,  which  is  put  upon  the  stretch  by  the  con- 
traction of  the  internus.  The  necessity  for  early  treatment  in 
these  cases  arises,  not  for  relief  of  the  deformity,  but  to  pre- 
sers-e  the  eyesight 

Diagnosis. — The  diagnosis  as  a  usual  thing  is  easily  made, 
the  squinting  eye  not  being  directed  towards  an  object  held 
before  the  patient;  but  in  some  cases  the  deviation  is  not  very 
great,  and  there  may  be  some  doubt  as  to  which  is  the  affected 
eye.  In  such  cases  the  patient  should  be  directed  to  look  at 
the  top  of  the  finger  of  the  surgeon,  while  each  eye  is  alter- 
nately shaded  with  a  card  or  the  hand.  The  squinting  eye 
moves  when  the  other  is  covered,  since  the  patient  now  directs 
it  to  the  object;  the  other  eye  does  not  move  when  the  squint- 
ing eye  is  covered. 

The  differentiation  between  a  concomitant  squint,  and  a 
paretic  or  paralytic  squint  arising  from  affections  of  the  exter- 
nal rectus,  is  determined  by  the  primary  and  secondary  devia- 
tions, or  squint,  being  equal  in  the  former,  while  in  the  latter, 
if  the  sound  eye  is  being  watched  behind  the  card  while  the 
patient  regards  the  near  object,  the  motion  of  the  sound  eye 
inward  is  much  greater,  and  in  addition  there  will  be  a  loss 
of  movement  of  the  eye  in  the  direction  outward. 

The  degree  of  squint  is  measured  by  noting  the  distance 
between  a  vertical  line  drawn  through  the  centre  of  the  pupil 
and  the  lachrymal  punctum  of  the  lower  lid.  An  ivory  scale 
or  strabismometer  (Fig.  48)  graded  in  lines  or  half  lines  or 
millimetres  may  also  be  used.  This  is  placed  against  the  lower 
lid  of  the  squinting  eye  and  the  point  of  the  vertical  meridian 
of  the  cornea  is  noted ;  the  other  eye  is  now  covered  and  the 
deviation  noted  in  the  same  way,  and  the  difference  between 
the  measurements  thus  made  gives  the  amount  of  squint  in 
lines  or  millimetres.  The  vision  of  each  eye  should  be  tested, 
and  together  with  the  amount  of  refractive  error  recorded,  as 


CONVERGENT  STRABISMUS. 


121 


well  as  the  amount  of  squint,  and  the  relative  strength  of  the 
external  recti  muscles  will  have  a  bearing  upon  the  operative 
treatment  in  some  cases. 

Treatment. — While  convergent  strabismus  shows  a  ten- 
dency to  lessen  as  age  advances,  yet  the  importance  of  early 
operative  treatment  cannot  be  too  strongly  insisted  upon,  as 
the  sight  is  often  sacrificed  from  the  delay  occasioned  by  the 
expectation  of  improvement  with  age. 

If  the  case  applies  for  treatment  before  the  squint  becomes 
fixed,  the  use  of  atropine  to  paralyze  the  accommodation  of  the 
sound  eye,  or  both  eyes,  by  preventing  near  vision,  lessens  the 
tendency  to  convergence.     If  the  eye  has  become  permanently 
fixed  and  an  early  operation  is  not  desired,  the 
use  of  a  bandage  over  the  sound  eye  for  stated 
periods  daily  mil  retain  and  increase  the  visual 
power  of  the  afi'ected  eye;  still  better  is  the 
use  of  atropine  in  the  sound  eye,  which  will 
compel  the  squinting  eye  to  again  participate 
in  the  act  of  vision.     The  greatest  objection  to 
the  use  of  atropine  is  the  photophobia  which 
arises  from  the  dilatation  of  the  pupil.     These 
measures  may  prevent  temporarily  the  increase 
of  the   squint  and  the  advancing  amblyopia, 
but  the  most  effective  results  will  be  obtained 
by  the  use  of  proper  convex  glasses  as  deter- 
mined by  the  ophthalmoscope,  when  the  use 
FIG.  48.  q£  ^jjgjjj  jg  deemed  practical  in  young  children. 

In  many  cases  of  squint  the  use  of  certain  homoeopathic  rem- 
edies in  the  early  stages  has  relieved  the  tendency  to  perma- 
nent strabismus.  The  most  useful  remedies  are  Belladonna, 
Aconite,  Gelsemium,  Hyoscyamus  and  Jaborandi.  The  remote 
causes,  however,  more  frequently  determine  the  remedy;  as 
squint  arising  during  dentition  may  demand  Chamomilla, 
Belladonna,  or  Hyoscyamus;  while  if  dependent  upon  some 
irritation  of  the  digestive  tract,  Santonine,  Cyclamen,  Mer- 
curius,  Spigelia  or  Sulphur  may  be  beneficial. 

Convulsions  or  whooping  cough  may  indicate  Belladonna, 


122  DISEASES  AND  INJURIES  OF  THE  EYE. 

Hyoscyamus,  Cuprum,  Agaricus,  Stramonium  and  Phosphorus. 
Some  cases  following  measles  and  scarlatina  I  have  relieved 
by  the  use  of  Belladonna,  Cyclamen,  and  Phos.  Acid;  but 
care  must  be  taken  to  improve  the  nutrition,  as  such  cases  do 
not  present  the  squint  except  when  the  stomach  is  empty,  or 
during  the  early  stages  of  a  meal.  Benefit  is  often  derived  by 
increasing  the  number  of  meals  during  the  day  temporarily, 
or  prescribing  a  table-spoonful  of  some  native  wine  just 
before  meals. 

If  the  methods  already  stated  do  not  improve  the  condition 
then  tenotomy  of  the  internal  rectus  becomes  necessary,  and 
its  early  performance  should  be  insisted  upon.  In  uncom- 
plicated cases,  the  prognosis  is  very  favorable.  The  operation 
consists  in  the  division  of  the  internal  rectus  at  its  tendinous 
insertion  into  the  sclerotic,  and  its  subsequent  re-attachment 
farther  back  to  allow  the  eye  to  resume  its  normal  position. 
The  time  for  the  performance  of  the  tenotomy  will  depend 
upon  the  permanency  of  the  squint  and  the  condition  of 
the  vision  of  the  squinting  eye.  If  the  vision  is  poor  the 
child  may  be  operated  upon  at  two  years  of  age,  but  usually 
better  results  are  obtained  after  six  years  of  age,  the  effort 
ha^dng  been  made  to  maintain  vision  in  the  poor  eye  by 
methodical  exercise.  If  the  squint  is  periodic,  or  alternating, 
there  is  no  danger  of  the  sight  diminishing  unless  the  squint 
becomes  permanent,  and  the  operation  may  be  delayed  until 
then.  Binocular  vision  is  more  frequently  obtained  where  the 
operation  is  made  early  in  life,  but  probably  not  over  one  third 
of  the  cases  operated  upon  regain  binocular  vision,  although 
parallelism  of  the  eyes  results.  The  amount  of  convergence 
must  be  the  guide  as  to  whether  one  or  both  internal  recti 
require  division,  the  fact  that  only  one  eye  squints  having 
nothing  to  do  with  making  the  decision.  Both  eyes  are  to  be 
operated  upon  whenever  the  degree  of  squint  amounts  to  over 
three  lines,  or  6  mm.  If  it  is  desirable,  the  operation  may 
be  made  to  correct  one  half  of  the  squint,  and  after  two  or 
three  weeks  a  slighter  operation  may  be  made  upon  the 
squinting  eye.     Equally  good  results  are  obtained  when  both 


OPERATION  FOR  CONVERGENT  SQUINT. 


123 


eyes  are  operated  upon  at  the  same  time.  In  all  cases  where 
the  squint  is  less  than  three  lines,  the  tenotomy  should  be 
made  upon  the  squinting  eye  alone. 

After  the  eyes  are  again  parallel  as  a  result  of  the  opera- 
tion the  use  of  glasses  to  correct  the  refraction  may  be  neces- 
sary in  order  to  prevent  a  return  of  the  squint  and  maintain 
binocular  vision. 

OPERATION  FOR  CONVERGENT  SQUINT. 

For  the  operation  a  speculum,  a  pair  of  strabismus  or  fixa- 
tion forceps  (Fig.  49),  a  pair  of  curved  scissors  (Fig.  50)  and 


FIGS.  49  &  50. 


two  strabismus  hooks  (Fig.  51)  are  necessary.  The  patient  is 
to  be  etherized  in  a  recumbent  position,  and  the  operator 
stands  behind  the  head,  or  at  the  side,  as  desired.  Adults 
usually  undergo  the  operation  without  the  use  of  anaesthetics, 
but  for  children  ether  or  chloroform  should  be  used  in  accord- 
ance with  the  judgment  of  the  operator.  The  speculum  is 
introduced  and  holds  the  lids  apart.       If    the  eyeball  rolls 


FIG.  51. 


upward  under  the  influence  of  the  anaesthetic,  the  conjunctiva 
below  the  cornea  is  caught  by  the  forceps  and  the  eye  rotated 
downward  into  position;  the  conjunctiva  and  subconjunctival 
tissues  over  the  insertion  of  the  internal  rectus  muscle  are 
now  seized  by  the  strabismus  forceps  and  cut  through  with  the 


124 


DISEASES  AND  INJURIES  OF  THE  EYE. 


scissors,  a  small  opening  being  made  either  vertically  or  hori- 
zontally, and  the  strabismus  hook  introduced  into  the  opening 
and  passed  beneath  the  tendon,  which  is  then  raised  upon  the 
iook  and  carefully  divided  by  several  snips  with  the  scissors 
«lose  to  the  sclerotic,  as  in  Fig.  52.     The  hook  is  again  intro- 


FIG.  52. 


duced  to  ascertain  whether  all  of  the  fibres  of  the  tendon  have 
been  divided,  care  being  taken  not  to  produce  much  separa- 
tion of  Tenon's  capsule  by  sweeping  the  hook  too  far  round. 
There  is  usually  a  great  deal  of  blood  effused  into  the  subcon- 
junctival tissue  following  the  division  of  the  tendon.  The 
more  extensive  the  division  of  Tenon's  capsule,  the  greater 
will  be  the  effect  of  the  operation,  and  much  judgment  and 
experience  is  necessary  to  decide  how  much  will  be  required  in 
any  given  case.  The  effect  of  the  operation  can  be  lessened 
by  the  introduction  of  a  suture.  To  do  this  a  curved  eye- 
needle  after  being  threaded  "with  fine  black  silk  is  placed  in 
the  needle-holder  (Fig,  53),  and  the  conjunctiva  at  the  mar- 
gin of  the  cornea  held  by  a  pair  of  forceps  while  the  needle 
is  passed  through,  and  then  through  the  conjunctiva  over  the 
muscle,  and  the  conjunctival  wound  brought  together.  This 
should  be  done  before  the  patient  recovers,  and  if  not  needed, 


OPERATION  FOR  CONVERGENT  SQUINT.  125 

is  easily  removed  afterwards.  The  patient  is  roused  from  the 
anaesthetic  and  made  to  look  at  the  finger,  held  a  foot  distant 
before  the  eye,  and  the  position  of  the  eyes  noted.  If  the 
amount  of  the  operation  has  been  well  gauged  the  eyes  will 
fix  properly  upon  the  object.  The  eye  should  then  be  directed 
towards  the  divided  muscle,  and  if  squinting  results,  or  the 
eye  moves  inward,  some  fibres  of  the  tendon  have  escaped 
cutting  and  the  hook  must  be  introduced  and  the  fibres  caught 
up  and  divided.  As  soon  as  the  effect  of  the  anaesthetic  has 
__        ^^^     l^.^1™^  passed   oflf,    the 

^^^•53.  vision   is    good 

and  the  action  of  the  musclfes  correct,  the  patient  should  be 
able  to  fix  tlie  eyes  upon  an  object  held  eight  or  ten  inches 
before  him.  If  the  eye,  after  a  few  moments,  diverges,  then 
the  operation  has  been  excessive  and  a  suture  should  be  intro- 
duced to  lessen  the  effect.  If  the  vision  is  poor,  or  the 
muscles  weak,  a  convergence  at  twelve  inches  is  sufiicient. 
After  the  operation  the  eye  should  be  bathed  with  cold  water 
or  a  decoction  of  calendula  flowers,  no  bandage  being  worn 
except  from  the  clinic  or  office  to  the  patient's  home. 

Diplopia  is  complained  of  in  some  cases  on  the  second  day, 
but  usually  disappears  as  the  muscle  regains  power,  and  is  not 
an  unfavorable  symptom.  In  some  cases  there  is  often  a  slight 
divergence  for  a  few  days  or  a  week.  The  improvement  in  the 
vision  of  the  squinting  eye  is,  oftentimes,  almost  immediate, 
the  loss  of  function  here  being  dependent  upon  the  tension  of 
the  recti  muscles. 

If  the  external  rectus  is  weak,  and  the  patient  consents  to 
have  only  one  eye  operated  upon,  a  strong  suture  may  be 
introduced  through  a  large  fold  of  the  conjunctiva,  which  is 
picked  up  by  the  forceps  between  the  outer  margin  of  the 
cornea  and  the  external  canthus,  the  two  ends  of  the  sutures 
armed  with  needles  being  carried  through  the  skin  of  the 
external  canthus,  one  above  and  one  below,  so  that  they  are 
separated  one-eighth  of  an  inch,  and  then  tied.     The  eye  is 


126  DISEASES  AND  INJURIES  OF  THE  EYE. 

thus  held  in  proper  position  until  the  tendon  becomes  re-at- 
tached, which  results  after  forty-eight  hours,  when  the  suture 
is  removed.  Severe  reaction  sometimes  follows  the  introduc- 
tion of  these  counter-sutures,  which  can  readily  be  controlled 
by  the  use  of  cold  compresses.  Other  operations  for  tenotomy 
are  used  by  various  surgeons  according  to  individual  ideas; 
when  a  slight  correction  only  is  necessary  it  may  be  done  by 
making  a  short  horizontal  incision  in  the  conjunctiva  and 
iBubconjunctival  tissue  at  the  lower  border  of  the  insertion  of 
the  tendon,  passing  in  the  hook  and  dividing  the  tendon 
aa  before;  the  hemorrhage  is  very  slight  and  there  is  less 
tendency  to  sinking  of  the  caruncle.  The  eyeball  becomes 
slightly  more  prominent  after  tenotomy  and  there  is  a  corres- 
ponding sinking  of  the  caruncle.  In  some  cases  a  mass  of 
^anulations  are  developed  about  the  stump  of  the  tendon, 
which  becomes  pedunculated  as  the  conjunctiva  heals  around 
it,  and,  either  drops  off  spontaneously,  or  may  be  clipped  with 
the  scissors.  If  the  operation  has  been  excessive,  a  divergent 
squint  will  result,  and  require  the  advancement  of  the  inser- 
tion of  the  opposite  muscle. 

DIVERGENT   STRABISMUS. 

This  condition  is  much  less  frequent  than  the  one  already 
described,  and  is  produced  by  the  increased  strength  of  the 
■external  recti  over  the  internal. 

Causes.  —  In  myopia,  which  causes  the  larger  number  of 
-cases  of  divergent  squint,  the  accommodation  is  exercised 
nrhen  they  converge,  although  the  accommodation  is  an  impedi- 
ment to  vision.  If  the  patient  is  myopic,  say  -^j,  with  either 
■eye  he  sees  distinctly  objects  eighteen  inches  distant,  but  if 
both  eyes  are  used  he  converges  and  hence  accommodates. 
The  object  is  now  only  seen  at  a  distance  of  eight  or  ten  inches 
irom  the  eyes.  This  gives  rise  to  pain  and  fatigue,  and  binoc- 
ular vision  is  apt  to  be  sacrificed  for  comfort,  especially  if  the 
refraction  of  both  eyes  differs  so  that  the  image  of  one  eye  is 
less  distinct  than  the  other.     The  more  defective  eye  is  then 


DIVERGENT  STRABISMUS.  127 

allowed  to  be  drawn  outward  by  the  external  rectus,  which, 
opposes  the  fatigued  internal  rectus,  and  divergent  squint 
results.  In  bad  cases  there  is  not  infrequently  some  shorten- 
ing of  the  superior  oblique  muscle  also.  This  squint  may  be 
periodic,  alternating,  or  permanent. 

If  the  eye  is  emmetropic,  then  the  squint  results  from  a 
paresis  or  insufficiency  of  the  internal  recti.  If  one  eye  is 
emmetropic  and  the  other  myopic  no  convergence  is  needed, 
as  the  former  is  used  for  distance  and  the  latter  for  near 
vision.  Opacities  of  the  cornea  and  vitreous,  and  diseases 
aflfecting  the  choroid  and  retina,  are  other  predisposing  causes, 
the  vision  being  so  poor  that  convergence  is  not  needed,  and 
the  external  rectus  turns  the  eye  passively  outward. 

Diagnosis. — Divergent  strabismus  is  distinguished  from 
paresis  and  paralysis  of  the  internus,  by  the  primary  and 
secondary  deviations  being  equal  in  concomitant  divergent 
squint.  Thus  when  the  affected  eye  suffers  from  paralytic 
squint,  if  the  healthy  eye  is  covered  by  the  hand  and  the 
patient  directed  to  look  at  an  object  which  is  moved  in  the 
direction  of  the  paralyzed  muscle,  an  effort  will  be  made  to  do 
it,  this  effort  will  be  transmitted  to  the  conjugate  muscles  of 
the  other  eye,  and  the  healthy  eye  will  squint  more  than  the 
paralyzed  eye.  While  if  the  squinting  is  concomitant,  the 
primary  deviation  of  the  effected  eye  will  be  equal  to  the 
secondary  deviation  of  the  well  eye. 

Treatment. — When  dependent  upon  refractive  error  proper 
glasses  are  to  be  provided  and  worn  as  detailed  in  Myopia.  If 
the  case  is  not  soon  relieved  the  full  correction  of  the  myopia 
should  be  made,  unless  the  condition  of  the  eye  is  such  as  to 
forbid  it.  Usually  the  condition  is  permanent  before  applica- 
tion for  relief  is  made,  and  tenotomy  of  the  internal  rectus  is 
necessary.  The  operation  is  made  in  the  same  manner  as  that 
described  for  the  internus.  The  change  in  position  of  the 
eyeball,  and  the  insertion  of  the  tendon  at  a  greater  distance 
from  the  cornea  are  to  be  borne  in  mind.  If  the  internal 
rectus  is  in  good  condition,  the  division  of  the  external  rectus 
will  lessen  the  deformity  3  to  4  mm.      If  the  correction  by  a 


128 


DISEASES  AND  INJURIES  OF  THE  EYE. 


single  tenotomy  is  not  sufficient,  both  externi  may  be  divided,, 
the  danger  of  over-correction  not  being  very  great.  In  bad 
cases  a  better  result  is  obtained  by  the  advancement  of  the 
internal  rectus. 

SuRSUMVERGENT  STRABISMUS  is  due  to  the  abnormal  develop- 
ment of  the  superior  rectus,  and  the  patient  squints  upward. 
It  is  readily  diagnosed  from  paralysis  of  the  inferior  rectus. 
It  is  very  rare,  and  in  two  cases  which  I  have  observed  the 
squint  was  congenital.  One  was  relieved  by  tenotomy  of  the 
superior  rectus. 

Deorsumvergent  strabismus  is  due  to  a  contraction  of  the 
inferior  rectus,  and  the  patient  squints  downward.  It  is  still 
more  rare  than  the  opposite  condition  and  may  be  relieved  by 
a  tenotomy. 

THE  ADVANCEMENT  OF  THE  MUSCLE. 

This  becomes  necessary  if  a  muscle  is  excessively  weak^ 
paralyzed,  or  the  tendon,  after  an  operation,  has  become 
attached  too  far  back;  the  design  being  to  increase  the  power 
of  the  muscle  by  shortening  it.  There  are  several  ways  of 
making  this  operation,  which  consists  simply  in  dividing  the 
tendon  at  its  insertion,  and,  by  means  of  sutures,  bringing  it 
forward  so  that  it  may  become  reattached  nearer  to  the  cornea. 
Not  more  than  4  mm.  can  be  corrected  in  this  way.  If  the 
divergence  requires  it,  a  second  correction  may  be  made. 

For  the  operation  the  patient  should  be  etherized,  the  lids 
separated  by  a  speculum,  and  the  tendon  of  the  opposing 
muscle  divided  and  allowed  to  drop  back.  The  tendon  of  the 
squinting  muscle  is  then  taken  up  on  the  hook,  and  before 
division  two  fine  black  silk  sutures  with  a  needle  at  each  end, 
are  passed  from  the  under  side  of  the  tendon  as  far  back  as  is 
necessary,  one  through  its  upper  portion  and  the  other  through 
the  lower:  the  needles  of  the  inner  portions  of  the  sutures  are 
then  passed  through  the  conjunctiva  above  and  below  the 
corneal  margin,  care  being  taken  not  to  change  the  position 
of  the  vertical  meridian ;  the  tendon  is  then  cut  and  the  ends  of 
the  sutures  brought  together  and  tied.     The  ends  of  the  ten- 


ADVANCEMENT  OF  THE  MUSCLES— NYSTAGMUS.  129 

don  overlap,  and  it  may  be  necessary  to  cut  away  a  portion  of 
the  tissue  in  front  of  the  tendon;  the  sutures  are  left  in 
position  four  or  jBve  days  until  union  takes  place.  The  eye  is 
bandaged  and  undue  reaction  prevented  by  cold  applications, 
and  Aconite  or  Calendula.  When  the  internal  rectus  is  to  be 
advanced  without  division  of  the  external,  the  result  of  the 
operation  is  made  surer  by  the  use  of  a  suture  passed  through 
the  conjunctiva  below  the  cornea,  between  the  cornea  and 
outer  canthus,  and  then  brought  inwards  and  passed  through 
the  cuticle  of  the  bridge  of  the  nose  and  tied.  The  use 
of  De  Wecker's  double  clamp  strabismus  hook  materially  aijis 
the  operation  by  holding  the  tendon  firmly  and  preventing  its 
slipping  back,  an  accident  which  is  liable  to  occur. 

NYSTAG^IUS. 

Nystagmus  is  usually  a  congenital  affection  of  the  ocular 
muscles,  characterized  by  a  pecular  oscillatory  movement  of 
the  eyeball,  which  becomes  more  rapid  during  efforts  to  see 
near  objects  or  under  excitement.  It  manifests  itself  in 
infancy  and  is  generally  associated  with  anomalies  of  refrac- 
tion, together  with  opacities  of  the  cornea  or  lens,  and  lesions 
of  the  choroid,  retina,  or  optic  nerve.  In  some  cases,  with  the 
absence  of  objective  lesions,  a  cure  has  followed  the  use  of 
either  Hyoscyamus,  Belladonna  or  Stramonium.  In  other 
cases,  in  older  children,  the  use  of  glasses,  particularly  for  the 
correction  of  hypermetropia  and  astigmatism,  has  given  good 
results.  In  the  acquired  form  it  is  frequently  presented  by 
coal  miners,  the  condition  arising  from  the  narrowness  of  the 
drift  in  which  they  are  working,  which  requires  the  prolonged 
use  of  the  eyes  in  an  upward  direction.  The  condition 
frequently  disappears  with  return  to  the  outside  world  and 
from  prolonged  rest. 


CHAPTEE   VII. 

DISEASES  OF  THE  OEBIT. 

ANATOMY. 

The  bony  cavities  which  contain  the  eyeball  and  its  acces- 
sories are  pyramidal  fossae,  irregularly  quadrilateral,  with 
their  bases  directed  forward  and  slightly  outward,  their  inner 
walls  being  nearly  parallel,  while  the  outer  walls  diverge  so  as 
to  be  nearly  at  right  angles  to  each  other.  The  roof  of  the 
orbit  is  formed  by  the  orbital  process  of  the  frontal  and  small 
wing  of  the  sphenoid,  and  is  somewhat  concave  and  smooth. 
Anteriorly  it  divides  into  two  plates  which  inclose  the  frontal 
sinus,  while  posteriorly  it  separates  the  orbit  from  the  cranial 
cavity  and  the  overlying  anterior  lobes  of  the  brain.  At  its 
anterior  margin  is  the  supra-orbital  foramen  or  notch,  while  at 
the  external  angular  process  is  the  depression  for  the  lach- 
rymal gland.  The  floor  is  formed  anteriorly  by  the  orbital 
processes  of  the  malar  and  superior  maxillary  bones,  and  at 
the  posterior  part  by  the  small  orbital  plate  of  the  palate 
bone.  It  is  grooved  for  the  infra-orbital  nerv^e,  and  below  it 
lies  the  antrum  of  Highmore.  The  inner,  or  nasal  wall,  is 
smoother  and  thinner  than  the  others,  and  is  formed  by  the 
processes  of  the  superior  maxillary,  the  lachrymal,  ethmoid, 
and  sphenoid.  In  the  anterior  portion  is  the  lachrymal 
groove  for  the  reception  of  the  lachrymal  sac,  formed  by  the 
superior  maxillary  and  lachrymal  bones,  and  leading  into  the 
nasal  duct.     In  its  posterior  portion,  between  the  ethmoid  and 


DISEASES  OF  THE  ORBIT. 


131 


frontal  bones,  are  two  foraminae,  the  more  anterior  giving 
passage  to  the  nasal  branch  of  the  ophthalmic  nerve  into  the 
cranium,  and  the  posterior  to  an  artery  into  the  nose.  The 
outer  wall  inclines  outward,  is  nearly  flat  and  made  up  of  the 
orbital  surfaces  of  the  malar  bone  and  the  great  wing  of  the 
sphenoid,  and  is  strengthened  by  the  zygomatic  process.  The 
sphenoidal,  or  superior  orbital  fissure,  at  its  inner  extremity 
occupies  the  apex  of  the  orbit,  while  its  outer  and  narrower 
part  lies  between  the  roof  and  the  external  wall.  Through  this 
fissure,  pass  the  ophthalmic  veins,  the  third,  fourth,  and 
branches  of  the  ophthalmic  division  of  the  fifth,  and  the  sixth 
nerves.  The  foramen  opticum,  for  the  passage  of  the  optic 
nerve  and  the  ophthalmic  artery,  is  internal  and  superior  to 


the  sphenoidal  fis- 
sure. It  is  a  short 
mm.    long 


canal, 

and    ( 

lined 

mater. 


FIG.  54. 


I  mm.  wide, 
by  the  dura 
In  the  angle 
between  the  outer 
wall  and  the  floor  is 
the  spheno-maxillary 
or  inferior  orbital 
fissure,  which  trans- 
mits the  superior 
maxillary  nerve, 
branches  from  Meckel's  ganglion,  and  the  infra-orbital  artery. 
The  margin  of  the  orbit  presents  a  rounded  edge,  and  is  com- 
posed of  dense  bony  tissue  capable  of  great  resistance,  spe- 
cially designed  for  the  protection  of  the  soft  tissues  inclosed  in 
the  orbit.  The  bony  walls  of  the  orbit  are  covered  with  peri- 
osteum, which  is  loosely  attached,  except  at  the  optic  foramen 
and  the  orbital  margin.  The  dura  mater  at  the  edge  of  the 
optic  foramen  forms  a  thick  tendinous  ring  from  which  the 
recti  muscles,  superior  oblique  and  levator  palpebrse  arise  As 
it  leaves  the  foramen  opticum  it  divides  into  two  parts,  the 
one  forming  the  periosteum  of  the  orbit  which  is  continuous 


182  DISEASES  AND  INJURIES  OF  THE  EYE. 

with  that  of  the  frontal  and  facial  bones.  At  the  margin  of 
the  orbit  a  portion  is  reflected  to  cover  the  tarsal  ligaments 
forming  the  tarso-orbital  fascia  for  the  retention  of  the  con- 
tents of  the  orbit.  The  other  portion  of  the  dura  mater  forms 
a  sheath,  for  the  optic  nerve  and  the  posterior  three-fourths  of 
the  eyeball,  termed  the  capsule  of  Tenon.  This  fascia  sepa- 
rates the  eyeball  from  the  muscles  and  fat,  and  enables  it  to 
roll  freely  in  all  its  movements,  and  is  lined  with  endothelial 
cells.  At  the  sclero-corneal  margin  a  part  of  the  fascia  is  lost 
in  the  sclera,  the  balance  passing  behind  the  conjunctiva  to 
the  tarsal  ligament  where  it  is  continuous  with  the  layer  form- 
ing the  periosteum,  thus  forming  a  closed  sac  containing  the 
tissues  of  the  orbit,  but  excluding  the  eyeball  and  optic  nerve ; 
within  this  fascia  is  a  continuation  of  the  arachnoidal  mem- 
brane from  the  brain,  and  the  space  between  the  two  is  con- 
tinuous with  the  arachnoidal  space  of  the  brain.  From  the 
tarso-orbital  fascia  delicate  prolongations  of  connective  tissue 
pass  into  the  orbit  to  support  the  fat  cells,  blood-vessels,  nerves- 
and  muscles.  The  arteries  of  the  orbit  are  derived  from  the 
ophthalmic  which  arises  from  the  internal  carotid  and  lies  in 
the  optic  foramen  to  the  outer  side  of  the  canal.  The  veins  of 
the  orbit  empty  into  the  cavernous  sinus,  which  is  separated 
from  the  orbit  by  the  tissue  of  the  sinus  itself. 

DISEASES  or  THE  OKBIT. 

The  diseases  of  the  orbit  most  commonly  met  with  are 
inflammation  of  the  cellular  tissue  filling  the  cavity,  capsulitis 
or  inflammation  of  Tenon's  capsule,  periostitis,  with  caries  and 
necrosis,  and  diseases  of  the  blood-vessels,  and  tumors.  All 
these  afi'ections  produce  an  increase  of  the  contents  of  the 
orbit  from  inflammatory  infiltration,  and  the  tarso-orbital  fascia 
being  resistant,  the  result  is  the  displacement  of  the  eyeballs 
forward,  or  exopMhalmus.  Protrusion  of  the  eyeball,  how- 
ever, is  not  always  due  to  orbital  lesions,  but  may  result  from 
inflammation  of  the  eyeball  itself  {panopMhalmUis)  ;  injuries 
resulting  in  the  dislocation  of  the  globe ;  paralysis  of  the  recti 


ORBITAL  CELLULITIS.  133 

muscles;  tumors  -within  the  eye;  myopia;  and  staphyloma  of 
the  sclera.  Again,  we  may  find  the  protrusion  due  to  affec- 
tions of  the  dura  mater,  as  in  hydrocephalus;  tumors  of  the 
brain;  diseases  of  the  lachrymal  gland;  and  diseases  and 
growths  of  the  frontal  sinus,  antrum  and  nasal  cavities.  The 
direction  of  the  displacement  of  the  eyeball  and  its  condition 
as  regards  size,  shape  and  mobility  will  enable  us  to  diagnose 
the  affection  which  is  productive  of  the  protrusion. 

ORBITAL  CELLULITIS. 

Inflammation  and  suppuration  of  the  cellular  tissue  of  the 
orbit  is  an  affection  of  much  gravity,  as  it  is  usually  fatal  to 
vision  and  not  infrequently  productive  of  death. 

Causes. — The  causes  are  more  frequently  those  from  injury 
of  the  orbit,  as  laceration  of  the  eyeball,  contusion,  or  punc- 
ture of  the  tissue  of  the  orbit  by  foreign  bodies,  or  opera- 
tions upon  the  eye,  as  after  tenotomy  of  the  muscles.  It  more 
rarely  appears  as  a  complication  of  periostitis,  extension  of 
erysipelas,  or  as  a  metastatic  abscess  in  pyaemia,  or  puerperal 
fever,  and  incidental  to  small-pox  and  meningitis. 

Symptoms  and  Diagnosis. — The  disease  commences  with. 
severe  pain,  usually  of  a  throbbing  character,  in  and  around 
the  eye,  extending  to  the  temporal  side  of  the  head  and  mus- 
cles of  the  neck,  accompanied  with  swelling  and  redness  of  the 
eyelids ;  fever  sets  in  and  the  patient  is  restless,  with  mild  deli- 
rium or  disturbed  dreams;  the  conjunctiva  becomes  chemosed 
or  swollen,  but  there  is  no  increased  discharge;  the  eyeball 
appears  immovable  and  is  rapidly  protruded  by  the  inflamma- 
tory effusion  into  the  contents  of  the  orbit.  The  resulting 
tissue  changes  are  exudation  from  the  overcharged  blood- 
vessels and  cell  prolification ;  this  results  in  a  matting  together 
of  the  muscles  and  other  tissues  of  the  orbit.  The  inflamma- 
tory process  may  extend  to  the  sheath  of  the  optic  nerve,  and 
a  neuritis  result,  or  the  pressure  of  the  contents  of  the  orbit 
interfere  with  the  circulation  in  the  nerve,  inducing  atrophy 
of  the  disc.    The  chemosis  of  the  conjunctiva  may  be  sufficient 


134 


DISEASES  AND  INJURIES  OF  THE  EYE. 


to  cause  sloughing  of  the  cornea,  or  the  whole  eyeball  may 
participate  in  the  inflammatory  action.  The  formation  of  pus 
is  characterized  by  rigors,  and  is  diffused  through  the  orbit,  or 
gradually  makes  its  way  towards  the  surface,  to  discharge 
through  the  conjunctiva,  or  skin.  Inflammation  of  all  the 
tissues  of  the  eye,  or  panophthalmitis,  may  complicate  the 
attack,  or  the  inflammatory  process  may  extend  backward,  and 
the  membranes  of  the  brain  become  involved,  with  the  pro- 
duction of  cerebral  symptoms. 

Differential  Diagnosis. — The  disease  will  be  most  likely 
to  be  mistaken  for  the  first  stage  of  purulent  conjunctivitis, 
but  the  absence  of  any  discharge  from  the  chemosed  conjunc- 
tiva will  determine  the  diagnosis.  It  differs  from  panophthal- 
mitis in  the  moro  or  less  fair  condition  of  the  vision;  from 
periostitis,  by  the  absence  of  diplopia  and  the  equal  dis- 
placement of  the  eyeball;  from  tumors  and  malignant  growths 
of  the  orbit,  by  the  presence  of  acute  inflammatory  symptoms 
and  pain. 

Duration  and  Prognosis. — The  disease  is  usually  very 
acute  and  passes  through  all  its  stages  in  a  few  weeks,  but 
certain  cases  may  become  chronic  and  last  for  months.  In  the 
acute  form  fluctuation  may  be  determined  by  the  eighth  or 
twelfth  day  at  one  or  more  points  at  the  upper  and  inner  part 
of  the  orbit.  The  pus  does  not  readily  point,  owing  to  the  dense 
tarso-orbital  fascia,  but  as  soon  as  the  pus  has  been  diagnosed 
and  evacuated  spontaneously,  or  by  the  knife,  the  pain  and 
swelling  diminish,  the  eyeball  recedes  and  the  parts  soon  retarn 
to  their  normal  condition.  The  eyeball  may  be  destroyed  by  the 
extension  of  the  inflammation,  or  pus  forming  in  the  interior 
will  require  an  incision  through  the  anterior  portion  of  the 
eyeball  for  its  discharge,  and  destruction  of  the  vision- with 
atrophy  of  the  eyeball  will  result.  The  pressure  of  the  con- 
tents of  the  orbit,  or  the  extension  of  the  inflammation  to  its 
sheath  will  cause  atrophy  of  the  optic  nerve.  Loss  of  motion 
of  the  eye,  or  atrophy  of  the  eyeball,  may  result  from  extensive 
destruction  of  the  orbital  tissue  or  necrosis  of  the  bones  of  the 
orbit.     The  chronic  variety  is  characterized  by  more  moderate 


ORBITAL  CELLULITIS— PERIOSTITIS.  135 

swelling,  pain  and  protrusion,  and  is  more  frequently  a  com- 
plication arising  from  periostitis  in  strumous  and  syphilitic 
patients. 

Treatment. — The  treatment  consists  in  the  constant  appli- 
cation of  ice  bags,  or  cold  compresses  in  the  early  stages ;  later, 
when  suppuration  is  inevitable,  the  use  of  hot  compresses,  and 
poultices,  are  indicated.  As  soon  as  pus  is  formed,  the  abscess 
should  be  opened  at  the  earliest  possible  moment.  If  fluctuation 
is  discernible,  a  free  incision  should  be  made  with  a  long  double- 
edged  cataract  knife  close  to  the  wall  of  the  orbit,  and  a  drainage 
tube  inserted.  If  the  diagnosis  of  pus  is  not  positive  and  the 
pain  is  great,  an  incision  with  a  linear  cataract  knife  should  be 
made  along  the  upper  or  lower  wall,  as  the  indications  may 
present,  and  if  pus  follows  the  knife,  a  tent  or  drainage  tube 
should  be  inserted. 

^  Aconite.  — When  the  inflammatory  symptoms  first  appear. 
The  lids  are  swollen  and  tense,  the  conjunctiva  chemotic,  and 
much  heat  and  general  sensitiveness  of  the  eye  and  surround- 
ing parts,  with  general  febrile  excitement  are  present. 

Bell. — Oftentimes  follows  the  use  of  Aconite  in  the  first 
stages  and  presents  the  same  indications  as  regards  the  eyes, 
except  that  the  hypereemic  condition  of  the  lids  is  usually  of  a 
darker  hue,  and  general  cerebral  congestion  is  present. 

Apis  mel. — In  the  first  stage  when  there  is  much  oedema  of 
the  lids  and  conjunctiva,  with  stinging,  shooting  pains  in  and 
around  the  eye.     Drowsy,  thirstless  condition. 

Rhus  tox. — One  of  the  most  valuable  remedies  for  the  first 
stage  of  cellulitis  whether  arising  from  injury  after  operation, 
or  from  ether  causes.  The  lids  and  conjunctiva  are  oedema- 
tously  swollen,  but  usually  harder  to  the  touch  than  under 
Apis.  The  pains  may  be  of  any  description.  The  general 
restlessness  is  very  marked. 

Phytolacca. — Stands  next  to  Ehus  in  value  for  cellulitis  but 
suits  sub-acute  and  chronic  cases  better.  The  pain  and 
inflammatory  symptoms  are  all  more  moderate.  The  lids  are 
hard,  as  is  also  the  orbital  tissue,  and  of  a  dark  color — often 
reddish  blue.       Additional  benefit  is  derived  from  the  external 


136  DISEASES  AND  INJURIES  OF  THE  EYE. 

application  of  cold  compresses,  wet  with  dilute  phytolacca  tinc- 
ture, before  the  suppurative  stage  has  been  established. 
Later  much  relief  will  be  obtained  by  the  use  of  a  poultice 
made  from  the  phytolacca  root. 

Lachesis.  —  This  remedy  has  cured  a  case  of  cellulitis 
following  a  tenotomy  of  the  internal  rectus  muscle,  reported 
by  T.  F.  Allen,  M.  D.  There  was  protrusion,  chemosis  and  puru- 
lent discharge,  with  sloughing  at  the  point  of  tenotomy,  with  a 
black  spot  in  the  centre  of  the  slough.  The  retina  was  hazy 
and  congested. 

Hepar  sulph. — For  the  suppurative  stage  or  when  it  is  inevi- 
table. The  lids  are  swollen,  red  and  extremely  sensitive  to 
touch  or  cold  applications.      The  pains  are  mostly  throbbing. 

Mercurius. — This  remedy  together  with  Hepar  will  shorten 
the  suppurative  stage,  and  after  the  pus  has  been  evacuated,  or 
as  it  becomes  thin  in  character,  the  reparative  process  will  be 
hastened. 

Kali  iod. — Very  useful  in  those  cases  of  partial  orbital 
cellulitis  occurring  in  young  children  of  syphilitic  con- 
stitutions. 

Arsenicum,  Bryonia,  Silicia  and  Sulphur  may  do  good 
service  in  some  cases  when  used  intercurrently. 

PERIOSTITIS. 

Periostitis  may  affect  any  portion  of  the  orbital  walls  and 
may  be  acute  or  chronic. 

Causes. — The  causes  which  give  rise  to  it  are  syphilis, 
injuries;  periosteal  inflammation  of  other  cavities  through 
continuity  of  tissue ;  exposure  to  cold  in  ill-nourished  and  low 
conditions  of  the  system. 

Symptoms  and  Diagnosis.  —  If  acute  it  is  difficult  to 
distinguish  from  orbital  cellulitis,  with  which  it  is  always 
accompanied  to  a  greater  or  less  extent.  The  cellulitis  is 
usually  more  localized,  and  the  tendency  to  localization  is 
greater  the  more  chronic  the  periostitis.  Where  an  acute 
periostitis  arises  from  some  lesion  of   the  orbital  walls  the 


PERIOSTITIS— REMEDIES.  137 

periosteum  is  detaclied  by  the  formation  of  pus  beneath,  it. 
The  displacement  of  the  eye  is  in  the  direction  opposite  to  the 
side  affected,  while  the  motion  of  the  eyeball  is  limited  in  the 
direction  of  the  side  affected.  If  it  arises  idiopathically 
the  tendency  to  the  formation  of  pus  is  much  lessened,  and 
the  eye  is  protruded  more  uniformly,  with  more  or  less  loss 
of  motion  in  all  directions.  Pressure  upon  the  eyeball  causes 
pain,  which  is  more  marked  if  the  periosteal  affection  is 
located  at  the  apex;  if  located  near  the  margin  or  upon  the 
walls,  the  pressure  of  the  tip  of  the  finger  just  within  the 
orbital  margin  may  determine  the  location  of  the  lesion  by 
the  sensitiveness  or  swelling. 

The  chronic  form  is  the  more  common  and  usually  develops 
from  injuries  at  periods  more  or  less  remote,  or  from  syphilis. 
Its  duration  may  continue  for  months,  or  years.  The  pain 
varies  with  the  situation  of  the  lesion,  occasioning  more 
suffering  when  located  at  the  apex  or  margin  than  in  other 
portions  of  the  walls  where  the  periosteum  is  more  loosely 
attached.  Exophthalmus  and  diplopia  are  commonly  present, 
and  in  old  cases  a  fistulous  opening  from  the  conjunctival  sac, 
upon  the  surface  of  the  lids,  or  upon  the  cheek,  exists.  Careful 
probing  through  this  opening  will  reveal  the  roughened 
surface,  or  necrosis,  of  the  bone. 

DiFFEEENTiAL  DiAGONSis.  —  Periostitis  is  to  be  differentiated 
from  orbital  cellulitis  by  the  more  acute  process  of  the  latter, 
the  greater  protrusion  of  the  eye,  the  loss  of  mobility  and 
defective  vision;  from  orbital  tumors  by  the  absence  of  pain 
and  inflammation ;  from  malignant  gro\\i;lis  by  the  early  impli- 
cations of  the  surrounding  tissues  and  lids;  from  Basedow's 
disease  by  the  staring  appearance  of  the  protruded  eyes  and 
the  motion  of  the  eyeballs. 

Tkeat3IENT. — This  consists  in  the  prevention  of  the  exten- 
sion of  the  diseased  condition  by  the  use  of  remedies,  the  early 
evacuation  of  the  pus,  thereby  lessening  further  suppuration 
of  the  periosteum,  and  the  improvement  of  the  patient's  general 
condition.  In  the  acute  forms  the  external  applications  of 
moist  heat  by  hot  compresses  or  poultices  tend  to  lessen  the 
pain  but  are  usually  of  little  value. 


138 


DISEASES  AND  INJURIES  OF  THE  EYE. 


If  the  attack  is  acute  the  patient  should  be  confined  to  bed, 
and  the  strength  sustained  by  proper  diet ;  in  the  more  chronic 
forms  the  patient  should  be  directed  to  use  nourishing  food, 
fresh  air,  and  avoid  exposure  to  cold  or  wet. 

If  it  is  probable  from  a  careful  inspection  of  the  condition 
that  pus  is  retained  beneath  the  periosteum,  it  should  be 
evacuated  by  the  aspirator,  or  a  free  incision  with  the  bis- 
toury. The  needle  or  knife  should  be  passed  close  to  the 
wall  of  the  orbit  and  away  from  the  eyeball.  After  the  pus 
has  been  evacuated  either  spontaneously,  or  by  the  knife,  a 
tent  should  be  constantly  kept  in  the  wound  so  as  to  allow  free 
drainage  until  the  bone  has  healed.  If  a  sequestrum  forms, 
the  external  opening  must  be  enlarged,  and  anti-septic  injec- 
tions employed,  and  the  piece  of  dead  bone  removed.  As  the 
fistulous  wound  heals  ectropium  may  result  from  the  cicatriza- 
tion. This  may  be  partially  prevented  by  narrowing  the 
palpebral  fissure  one-third,  or  one-half,  by  the  union  of  the  lid 
edges  after  their  scarification;  the  union  being  allowed  to 
remain  for  three  or  four  months,  or  until  it  is  probable  that 
there  will  be  no  further  contraction  of  the  wound.  Later  a 
subcutaneous  separation  of  the  cicatrix  may  be  made  with 
relief  to  the  lid. 

EEMEDIES. 

Asafoetida. — Proves  very  useful  in  relieving  both  the  pain 
and  inflammation  of  marginal  periostitis.  Tiie  parts  around 
the  orbit  are  blue,  with  great  sensitiveness  to  touch. 

Aurum  mur.  —  Periostitis  and  caries  with  a  tendency  to 
exostosis  in  syphilitic  patients;  the  pains  are  boring  in  char- 
acter, excruciating  and  referred  to  the  affected  bone :  nightly 
aggravation. 

Kali  iod. — Valuable  in  all  forms  of  periostitis,  but  particu- 
larly so  in  the  syphilitic  variety.  The  pains  are  worse  at  night 
and  vary  much  in  character.  In  some  cases  the  pain  may  be 
very  slight.  In  its  use  the  best  results  are  obtained  by  the 
administration  of  five  gr.  doses,  ier  in  die,  and  later  of  the  2nd 
or  3rd  trit. 


CARIES  AND  NECROSIS.  139 

Ferrum  phos. — This  remedy  produced  rapid  improvement 
in  a  case  otf  localized  periostitis  occurring  from  a  traumatic 
cause  in  a  child  of  strumous  habit.  There  was  marked  swell- 
ing of  the  lower  lid  and  great  sensitiveness,  with  ill-defined 
pains,  febrile  excitement  and  nocturnal  aggravation. 

Calc.  phos. — xA.s  a  nutrition  remedy  is  often  of  much  benefit 
in  cases  exhibiting  slight  reactive  power,  which  may  also 
require  Silicia  or  Mercurius. 

Mercurius. — Often  indicated  in  cases  of  periostitis  and  caries, 
when  the  general  cachectic  condition  presents  the  characteristic 
symptoms  of  the  remedy. 

Silicia. — In  a  condition  of  caries  where  fistulous  openings 
leading  to  the  diseased  bone  are  present.  The  parts  are  hard, 
swollen,  bluish-red,  and  the  pus  is  usually  offensive. 

The  following  remedies  may  prove  of  service  in  individual 
cases:  Calc.  fluor.,  Nit.  ac,  Calc.  carb.,  Hecla  lava,  and  Sulph. 

Cakies  and  Necrosis  of  the  orbital  walls  may  result  from 
periostitis  or  cellulitis,  or  take  place  in  consequence  of  direct 
violence,  particularly  in  strumous  or  syphilitic  cases.  The 
margin  of  the  orbit  is  more  frequently  the  seat  of  the 
trouble,  o^ing  to  its  exposed  position.  The  lids  become 
oedematously  swollen,  frequently  completely  closing  the  eye; 
the  conjunctiva  becomes  inflamed  and  an  abscess  points  upon 
the  upper  or  lower  lid  near  the  outer  canthus.  On  opening 
the  abscess,  dark-colored  and  badly-smelling  pus  is  discharged 
and  a  fistulous  opening  remains.  The  abscess  should  be 
opened  as  soon  as  possible  and  a  drainage  tube  introduced, 
and  the  dead  bone  removed  as  soon  as  loosened.  The  remedies 
likely  to  be  used  are  those  already  mentioned  under  the  head 
of  Periostitis. 

Capsulitis,  or  inflammation  of  Tenon's  capsule,  is  a  very  rare 
disease.  It  presents  slight  protrusion  of  the  ball,  deep  injec- 
tion of  the  sclera,  and  accompanying  chemosis  of  the  conjunc- 
tiva with  slight  loss  of  motion  in  all  directions.  The  absence 
of  inflammatory  changes  in  the  cornea,  iris  or  conjunctiva,  will 
differentiate  it  from  diseases  of  these  tissues.  The  causes 
which  produce  it,  are  direct  injuries  to  the  capsule   as  in  ten- 


140  DISEASES  AND  INJURIES  OF  THE  EYE. 

otomy  for  strabismus,  or  lacerations  of  the  eyebalL  It  may 
complicate  corneal,  or  suppurative  keratitis,  facial*  erysipelas, 
and  result  from  suppression  of  the  menses.  It  usually  runs  a 
mild  course  and  requires  for  its  treatment  warm  fomentations, 
"with  intervals  of  moderately  tight  bandaging.  The  remedies 
likely  to  be  of  servdce  are  Ehus,  Bryonia,  Phytolacca  and 
Apis. 

EXOPHTHALMIC  GOITRE. 

This  disease,  to  which  has  also  been  given  the  names  of 
Basedow  and  Graves,  is  characterized  by  a  protrusion  of  the 
eyeball,  due  to  vascular  enlargement,  hypertrophy  of  the  thy- 
roid gland,  cardiac  dilatation,  and  easily  excited  palpitation  and 
frequent  pulse.  All  these  lesions  may  not  be  present  in  every 
case.  Both  eyes  are  affected,  except  in  exceptionally  rare 
cases.  The  disease  is  common  to  both  sexes,  but  is  more 
freqtient  in  women.  It  is  probably  due  to  some  disturbance 
of  the  sympathetic  nervous  system,  and  frequently  arises  from 
reflex  irritation  of  the  genital  organs.  It  occurs  about  the  age 
of  puberty,  but  also  with  advanced  age. 

Symptoms  and  Diagnosis. — There  may  be  a  marked  differ- 
ence in  the  prominence  of  the  two  eyes,  which  present  a 
peculiar  stare,  a  portion  of  the  sclera  above  the  cornea  being 
exposed  by  a  slight  retraction  of  the  upper  lid.  Defective 
innervation  of  the  ocular  muscles  is  an  early  symptom  and  shows 
itself  in  the  slowness  of  the  levator  of  the  upper  lid  to  act  in 
the  vertical  movements  of  the  eyeball,  infrequency  and  slow- 
ness of  action  in  winking,  overflow  of  tears  and  diplopia.  The 
pupil  is  usually  normal  but  may  be  dilated.  The  vision  is  not 
impaired,  except  in  rare  cases  where  the  cornea  suppurates 
from  the  exposure  of  the  eyeball  resulting  from  its  protrusion 
and  the  retraction  of  the  lids.  In  this  case  the  attempt  may 
be  made  to  protect  the  eye  from  external  irritation  by  bandag- 
ing the  eyes,  by  the  union  of  the  lids,  and  if  ulceration  of  the 
cornea  superv^enes,  by  treating  it  as  described  in  the  chapter 
on  corneal  diseases.  The  heart  symptoms  are  accompanied  by 
a  rapid  pulse  which  varies  from  90  to  160,  or  more  a  minute, 


EXOPHTHALMIC  GOITRE— TREATMENT.  141 

and  easily  excited,  and  is  associated  with  a  flushed  face,  and  a 
general  hysterical  condition  of  the  patient.  The  enlargement 
of  the  thyroid,  due  to  vascular  engorgement,  is  usually  seen 
in  these  cases,  but  may  not  always  be  present.  The  concomi- 
tant symptoms  will  readily  differentiate  the  disease  from  other 
forms  of  exophthalmus.  The  disease  is  slow  in  its  progress 
and  after  a  time  the  heart  symptoms  may  disappear  and  the 
patient  recover,  or  the  digestion  may  fail  and  the  emaciation 
and  prostration  result  in  death  from  anaemia,  asthenia,  or 
phthisis. 

Treatment. — For  the  exophthalmus  nothing  is  necessary 
except  to  protect  the  exposed  balls  from  external  irritation  as 
far  as  possible.  If  the  cornea  becomes  dry  vaseline  applied  to 
the  ball  several  times  a  day  may  be  of  benefit,  and  bandaging 
is  oftentimes  a  relief  by  making  a  gentle  pressure  upon  the 
globes.  It  may  be  necessary  to  hold  the  lids  in  position  by 
plaster,  or  make  an  operation  for  their  partial  closure. 

Ulceration  of  the  cornea  is  to  be  treated  as  directed  in  the 
chapter  on  corneal  diseases. 

Galvanism  applied  every  other  day,  from  five  to  ten  minutes 
at  each  sitting,  with  the  negative  pole  to  the  cervical  region 
of  the  neck,  and  the  positive  pole  alternately  over  the  closed 
eyelids,  the  thyiKjid  gland,  and  over  the  cardiac  region,  has 
been  productive  of  much  good  in  some  cases.  Rest,  change  of 
occupation,  freedom  from  excitement,  especially  of  the  emo- 
tions, proper  exercise  in  the  open  air  and  a  generous  diet  with- 
out the  use  of  any  stimulants,  may  do  much  towards  improving 
the  condition  of  the  case  and  result  in  success  when  combined 
with  internal  medication.  The  homoeopathic  treatment  of  the 
disease  consists  in  the  relief  of  the  condition  by  a  careful 
study  of  the  totality  of  the  symptoms  presented.  Those 
remedies  which  have  been  useful  in  the  relief,  or  cure  of 
cases,  are  Amyl.  nit,  Badiaga,  Arsenicum,  Iodine,  Spongia, 
Cactus  grand,  Natrum  mur.  and  Baryta  carb.  Other  rem- 
edies have  given  relief  to  the  heart  symptoms  and  lessened 
the  exophthalmus,  as  Bell.,  Brom.,  Calcarea,  Phos.,  Sil., 
Sulphur  and  Ver.  vir. 


142  DISEASES  AND  INJURIES  OF  THE  EYE. 

TUMORS  OF  THE  ORBIT. 

All  portions  of  the  orbit  and  its  contents  may  serve  as  start- 
ing points  for  new  growths,  or  the  orbit  may  be  invaded  by 
tumors  extending  into  it  from  the  neighboring  cavities.  The 
amount  and  direction  of  the  displacement  of  the  eyeball  from 
orbital  tumors  will  depend  upon  the  size  and  situation  of  the 
growths.  If  the  tumor  is  located  at  or  near  the  apex  of  the 
orbit,  the  eyeball  is  protruded  directly  forwards,  the  nerves  and 
blood-vessels  become  compressed  and  the  vision  usually 
destroyed.  If  situated  upon  one  of  the  walls  the  eyeball  is 
displaced  in  a  direction  opposite  to  the  tumor,  with  resulting 
strabismus ;  the  loss  of  vision  varying  with  the  compression  or 
extension  of  the  growth  to  the  optic  nerve.  If  the  tumor  is 
located  at  the  margin  of  the  orbit,  the  displacement,  or  loss  of 
vision  may  not  occur.  Tumors  of  the  orbit  may  be  divided 
into  superficial  and  deep. 

If  superficial,  they  are  generally  fibrous,  fatty,  bony,  or 
muscular.  Fibromata  are  firm  to  the  touch  and  found  near 
the  orbital  margin ;  lipomaia  are  usually  seen  beneath  the  folds 
of  the  conjunctiva  on  eversion  of  the  lids.  They  generally 
start  from  the  cellular  tissue  of  the  orbit  and  are  benign. 
Osieomaia  are  very  hard  to  the  touch  and  slow  of  growth. 
Angiomata  more  frequently  arise  from  nsBvi  which  grow  back- 
ward from  the  skin  of  the  lids  into  the  cellular  tissue  of  the 
orbit.  Cystic  tumors  containing  cheesy  or  fatty  matters,  albu- 
minous fluid,  blood,  or  hair,  are  not  infrequently  met  with  in 
the  orbit  If  not  too  deep  they  may  be  felt  as  elastic  and 
slightly  movable  masses ;  they  are  usually  slow  in  progress. 
Degenerations  of  the  lachrymal  gland  may  present  either  a 
superficial  or  deep  growi;h.  Hydatids  enclosed  in  capsules, 
echinococci  or  cysticerci  are  found  in  the  orbit  and  may  be 
superficial  or  deep.  These  are  all  slow  and  painless  growths 
unaccompanied  by  inflammatory  symptoms. 

The  deep-seated  tumors  may  consist  of  any  of  the  varieties 
already  enumerated  or  present  the  features  of  malignant 
groAvths.     They  may  arise  in  the  orbit  or  puncture  its  walls 


TUMORS  OF  THE  ORBIT.  14:3 

from  the  surrounding  cavities  or  from  the  eyeball  itself. 
Beginning  protrusion  of  the  eye  gives  often  the  first  indication 
of  their  presence.  If  the  growth  of  the  tumor  is  slow  the  lids 
undergo  remarkable  distention  as  the  globe  advances,  or  they 
become  widely  separated  and  no  longer  give  protective  covering 
to  the  cornea  which  may  suffer  in  consequence  and  become 
inflamed  or  suppurate.  Again,  the  globe  may  be  pushed  out  on 
to  the  cheek,  the  lids  everted  and  the  eye  entirely  lost  In  the 
deep-seated  growths,  the  displacement  of  the  eye  becomes  very 
marked  and  the  sight  almost  always  destroyed.  Malignant 
tumors  are  characterized  by  a  more  rapid  growth,  and  unnatu- 
ral vascularity  of  the  surrounding  integument  and  enlargement 
of  the  veins,  and  are  commonly  of  the  sarcomatous,  medullary 
or  melanotic  varieties,  and  usually  involve  the  eye.  Either 
form  on  reaching  the  surface  extrudes  between  the  lids, 
becomes  fungoid,  bleeds  easily,  is  covered  by  an  offensive 
secretion,  emits  a  sickening  odor,  and  death  is  produced  by 
hectic  emaciation  or  exhaustion. 

Malignant  groAvths  are  much  more  common  in  children  than 
in  adults,  though  occurring  in  each  of  them.  Fibromata,  lipo- 
mata,  angiomata,  cystic  and  less  malignant  growths  increase  in 
size  much  more  slowly  and  prove  more  amenable  to  treatment. 

Diagnosis. — The  diagnosis  of  the  character  of  orbital 
growths  is  accomplished  with  the  greatest  difficulty,  and, 
except  in  some  cases  of  malignant  and  bony  tumors,  can  only 
be  made  during  the  process  of  removal.  It  is  always  uncer- 
tain, and  the  general  condition  of  age,  sex,  condition  of  health, 
cancer  heredity,  or  the  presence  in  other  organs  of  cancerous 
affections,  struma,  syphilis,  the  location  of  the  tumor,  its  proba- 
ble place  of  origin,  its  rate  of  progress,  the  presence  or 
absence  of  pain  and  inflammatory  symptoms,  the  involvment 
of  the  ocular  muscles  and  the  condition  of  the  vision  and  optic 
disc,  all  must  be  considered  in  endeavoring  to  make  a  diag- 
nosis. The  pressure  of  the  finger  around  the  globe  within  the 
margin  of  the  orbit  may  give  some  idea  as  to  the  mobility, 
hardness,  and  possible  location  of  the  tamor  upon  the  muscles 
or  walls  of  the  orbit.     The  prognosis  depends  upon  the  nature 


144  DISEASES  AND  INJURIES  OF  THE  EYE. 

of  the  tumor,  wlietlier  benign  or  malignant,  and  wliether  it  can 
be  removed  without  the  loss  of  the  eyeball. 

Cysiic  tumors  are  partially  movable;  bony  tumors,  on  the 
other  hand,  are  very  hard,  resisting,  and  immovable.  The  loss 
of  vision  depends  upon  the  involvment  of  the  optic  nerve 
in  the  tumor.  An  ophthalmoscopic  examination  of  the 
affected  eye  should  always  be  made.  Optic  neuritis  fol- 
lowed by  atrophy  is  present  when  the  optic  nerve  is  involved 
in  the  tumor.  If  optic  neuritis  is  present  in  both  eyes,  or 
choked  disc  in  the  otherwise  well  eye,  the  tumor  is  undoubtedly 
intra-cranial. 

Cartilaginous  and  hony  tumors  generally  follow  periostitis 
or  ostitis  in  strumous  or  syphilitic  subjects,  or  they  may  have 
a  traumatic  origin.  Pain  and  inflammatory  symptoms  are 
absent  unless  periostitis  also  exists. 

Fibrous  tumors  are  hard  to  the  touch  and  incompressible, 
non-inflammatory,  and  incased  in  a  connective  tissue  sheath ;  on 
dissection  a  gray,  yellow  or  brown  basis  substance  is  seen 
traversed  by  white  opaque  bands.  Removal  becomes  very 
difficult  when  situated  deeply  in  the  orbit. 

Sarcoma  of  the  orbital  tissues  is  of  frequent  occurrence 
and  may  arise  from  any  portion  of  the  orbital  tissues,  its  more 
common  seat  being  the  periosteum.  It  may  be  congenital  and 
exist  for  some  time  without  exhibiting  any  rapid  growth,  until, 
from  some  unknown  cause,  it  begins  to  increase  rapidly. 
Orbital  sarcomata  rapidly  excite  new  foci  and  infiltrate  sur- 
rounding tissues  or  more  distant  organs.  The  characteristic 
feature  of  the  sarcomatous  tumor  is  the  preponderance  of  the 
cellular  elements,  which  consist  of  hypertrophied  connective 
tissue  cells.  The  cells  are  either  round,  stellate,  or  spindle 
shaped,  and  form  with  the  entire  cellular  substance  a  tolerably 
firm  mass.  Sarcomata  may  acquire  a  medullary,  or,  if  the 
cells  are  filled  with  pigment,  melanotic  condition. 

When  the  sarcoma  has  its  origin  in  the  optic  nerve,  or  retina, 
and  involves  the  orbit,  it  appears  as  glio-sarcoma.  The  large 
celled,  especially  the  spindle  and  giant  celled  sarcomata,  are 
less  fatal  than  the  small  round  celled  variety,  while  the  melan- 


TUMORS  OF  THE  ORBIT. 


145 


otic  variety  is  particularly  infectious.  It  may  be  confounded 
in  its  early  stages  with  a  node,  but  the  absence  of  syphilitic 
history  will  decide  the  matter.  The  soft  and  smoother  surface 
of  the  growth  precludes  the  supposition  of  an  exostosis. 
These  tumors,  although  appearing  as  small,  hard,  nodulated 
masses,  form  extensive  attachments  to  the  orbital  cells;  if  un- 
disturbed, they  grow  steadily  until  the  overlying  skin  ulcer- 
ates and  the  patient's  health  fails. 

Cancerous  tumors  are  very  malignant  and  the  infection 
rapidly  spreads,  involving  all  the  tissues  of  the  orbit  and  the 
surrounding  cavities.  The  lymphatics  become  infiltrated  early 
and  the  cancer  cells  are  carried  to  other  parts.  The  protrusion 
of  the  eyeball  is  less  with  scirrhus  than  with  other  tumors,  the 
walls  of  the  orbit  being  rapidly  absorbed;  the  tumor  invades 
the  surrounding  cavities,  and  pressure  is  not  exerted  upon  the 
eyeball.  The  tumor  presents  a  firm  resistance  and  may  be 
mistaken  for  an  exostosis. 

Vascular  tumors  are  of  comparatively  rare  occurrence;  they 
form  in  the  cellular  tissue  of  the  orbit  and  increase  slowly 
and  usually  do  not  impair  the  patient's  health  or  vision.  The 
protrusion  disappears  ou  pressure  and  reappears  when  the 
pressure  is  removed.  It  becomes  larger  on  straining,  stoop- 
ing, or  crying,  and  often  a  slight  pulsation  is  present 
which  is  not  perceptible  to  the  patient.  They  may  be  caused 
by  intra-cranial  affections  which  interfere  with  the  return  cir- 
culation by  pressure  on  the  ophthalmic  vein.  The  diagnosis  is 
usually  very  difficult. 

Treatment. — The  treatment  consists  in  the  early  removal 
of  the  growths  when  practicable,  and  time  should  not  be  lost 
by  unavailing  medication.  Those  tumors  which  are  situated 
more  superficially  may  be  removed  either  through  the  con- 
junctival sac,  or  through  the  attachments  of  the  lids  without 
interfering  with  the  eyeball,  by  an  incision  parallel  to  the 
orbital  margin  and  over  the  most  prominent  point  of  the 
tumor;  all  bleeding  must  be  arrested  before  the  wound  is 
closed,  and  all  clots  removed  by  washing  out  the  wound  with 
boracic  acid  solution.     If    cellulitis  results,    ice  applications 

10 


146 


DISEASES  AND  INJURIES  OF  THE  EYE. 


may  prevent  its  extension  and  lessen  the  reaction.  "When 
situated  at  the  upper  margin  of  the  orbit,  ptosis  results  from 
the  incision  which  divides  the  levator,  or  the  removal  of  a  por- 
tion of  the  muscle  with  the  tumor. 

Cystic  tumors  may  be  evacuated  by  an  incision,  or  with  the 
aspirator,  and  irritating  injections  be  made  into  the  cystic  sac, 
resulting  in  a  union  of  the  cyst  walls  and  obliteration  of  the 
tumor.  Fatty  tumors  may  be  removed  without  danger,  unless 
the  extension  is  very  great.  Bony  tumors,  which  often  grow 
to  great  size,  in  rare  cases  yield  to  iodide  of  potash,  and  are 
difficult  to  treat,  for  resection  is  fraught  with  peril,  as  the  full 
extent  of  the  disease  is  uncertain  and  frequently  involves  the 
osseous  protection  of  the  brain.  When  their  removal  is 
attempted,  as  when  the  margin  alone  appears  involved,  the 
careful  separation  with  a  chisel  and  mallet  is  necessary. 

In  all  cases  the  question  arises  as  to  the  removal  of  the  tumor 
without  destruction  of  the  eyeball,  or,  the  removal  of  the  whole 
of  the  contents  of  the  orbit.  If  the  tumor  does  not  penetrate 
too  deep  and  is  bony,  the  eyeball  may  usually  be  saved.  In 
the  removal  such  muscles  ag  are  necessary  may  be  severed 
from  the  globe,  a  black  suture  being  passed  through  them  un- 
til after  the  removal  of  the  growth,  when  they  are  to  be  united 
in  proper  position  to  the  eyeball.  If  the  tumor  is  malignant 
or  deep,  and  involves  much  of  the  contents  of  the  orbit,  the 
vision  is  already  destroyed  by  involvment  or  compression  of 
the  optic  nerve,  so  that  the  removal  of  the  eyeball  and  the 
whole  of  the  contents  of  the  orbit  is  necessary.  AYhen  it  be- 
comes necessary  to  remove  the  eyeball  to  get  at  the  tumor,  the 
growth  if  bony  is  to  be  removed  with  as  little  destruction  of 
the  orbital  tissue  as  possible,  so  as  to  leave  sufficient  cushion 
for  the  wearing  of  an  artificial  eye. 

When  the  tumor  is  malignant  or  the  eyeball  involved,  the 
whole  of  the  contents  of  the  orbit  are  to  be  removed,  leaving 
the  periosteum  undisturbed,  if  after  close  inspection  it  is  not 
found  involved. 

The  operaUon  for  ihe  extirpation  of  the  contents  of  the 
orbit  is  performed  by  slitting  the  lids  at  the  outer  canthus,  and, 


TUMORS  OF  THE  ORBIT,  14=7 

having  the  lids  retracted  by  the  fingers  of  an  assistant,  intro- 
ducing a  pair  of  blunt  scissors  between  the  tumor  and  the 
orbit,  and  by  slowly  cutting,  pushing  and  tearing  while  keep- 
ing close  to  the  orbital  wall,  the  tumor  is  freed  from  the 
surrounding  tissues  up  to  the  apex  of  the  orbit,  when  the  masa 
may  be  torn  from  its  attachment  there.  The  hemorrhage  will 
depend  upon  the  vascularity  of  the  tumor  and  the  amount  of 
cutting  in  the  dissection,  but  is  most  profuse  when  the  tissues 
are  separated  at  the  apex.  It  may  be  necessary  to  stop  the 
hemorrhage  from  the  ophthalmic  artery  by  torsion,  but  it- 
usually  retracts  into  the  foramen,  and  if  the  bleeding  con- 
tinues the  apex  of  the  orbit  may  require  packing  with  styptic 
cotton,  which  is  retained  by  absorbent  cotton  tightly  packed 
upon  it,  and  a  compress  bandage  applied.  In  some  cases 
where  the  periosteum  is  involved,  the  walls  of  the  orbit  should 
be  washed  with  a  solution  of  chloride  of  zinc,  or  a  paste  of 
flour  and  chloride  of  zinc,  four  parts  of  the  former  to  one  of 
the  latter,  applied  to  the  infiltrated  parts.  Suppuration  nec- 
essarily follows,  and  daily  washing  of  the  cavity  with  anti- 
septic lotions  will  be  necessary,  and  the  orbit  finally  fills  with 
granulating  tissue.  The  growth  may  reappear  after  the  most 
painstaking  removal  and  require  a  secondary  operation,  when, 
the  bony  walls  should  be  scraped,  or  the  chloride  of  zinc  paste 
reapplied.  The  wearing  of  an  artificial  eye  is  not  practicable 
after  extirpation  of  the  contents  of  the  orbit,  as  the  granu- 
lating mass  does  not,  except  in  rare  cases,  become  covered 
with  epithelium  from  the  remaining  conjunctiva  of  the  lids, 
and  ptosis  results  from  the  excision  of  the  levator. 

Diseases  of  the  Blood-vessels  of  the  Orbit. — Aneurism 
of  the  ophthalmic  artery  and  diffuse  aneurism  of  the  orbit, 
vascular  growths,  varices  of  the  veins,  and  thrombus  of  the 
cavernous  sinus,  all  produce  what  is  termed  pulsating  exoph- 
ihalmus,  protrusion  of  the  eyeball  which  is  accompanied  by 
pulsation.  The  cases  are  rare  and  arise  spontaneously  or  from 
injury.  The  diagnosis  of  the  particular  lesion  producing  the 
exophthalmus  can  only  be  made  approximately.  It  develops 
rapidly  and  the  protrusion  varies  in  degree.     There  is  slight  or 


148  DISEASES  AND  INJURIES  OF  THE  EYE. 

no  pain,  bnt  weight  or  pressure  in  the  orbit  is  complained  of, 
and  the  pulsation  and  bruit  become  annoying.  The  pulsation 
is  early  discernible,  being  apparent  to  the  observer  on  ocular 
inspection,  or  to  the  touch,  while  with  the  stethescope  placed 
over  the  closed  lids  or  upon  the  upper  margin  of  the  orbit  a 
distinct  bruit  is  heard.  When  compression  of  the  carotid 
diminishes  or  stops  the  pulsation,  digital  compression  or  the 
ligation  of  the  internal  carotid  may  relieve  the  trouble.  In- 
jections into  the  cavity  of  the  orbit  are  fraught  with  much 
danger  and  rarely  do  good  in  these  cases.  Electrolysis  affords 
better  results. 

Diseases  of  the  Cavities  Surrounding  the  Orbit. — Dis- 
eases of  neighboring  sinuses  frequently  produce  disturbance 
of  the  orbital  tissues  and  exophthalmus.  Distension  of  the 
frontal  sinus  by  mucus,  or  pus  resulting  from  injury,  as  a 
blow  upon  the  face  which  has  fractured  the  ethmoidal,  or 
frontal  cells,  may  cause  a  closure  of  the  connecting  channel 
between  the  sinus  and  the  nose,  while  the  distended  sinus 
encroaches  upon  the  orbit.  The  accumulating  secretion  grad- 
ually distends  the  sinus  until  the  thinnest  portion,  the  roof 
of  the  orbit,  yields  and  is  pressed  down  into  the  orbit,  and 
displaces  the  eyeball  downward  and  outward;  this  may  arise 
from  closure  of  the  infundibulum  in  old  catarrhal  cases. 
Pain  and  inflammation  may  result,  and  the  pus  be  discharged 
into  the  nares  by  the  reopening  of  the  infundibulum.  If  this 
does  not  occur  it  requires  the  introduction  of  a  knife  along  the 
upper  wall  of  the  orbit,  a  careful  dissection  of  the  parts,  and 
after  the  dependent  portion  of  the  bone  is  exposed,  a  strong 
knife  is  passed  into  the  sinus  and  the  pus  removed ;  or  a  curved 
trochar  or  bistoury  is  introduced  through  the  sinus,  while  the 
little  finger  is  passed  up  the  corresponding  side  of  the  nose  and 
furnishes  a  guide  for  the  passage  of  the  bistoury,  or  trochar, 
into  the  nasal  cavity  through  which  the  pus  is  discharged.  A 
lead  wire,  or  rubber  drainage  tube,  is  passed  into  the  opening 
and  kept  in  position  until  the  discharge  from  the  nose  has 
ceased.  The  cavity  should  be  washed  daily  with  some  disin- 
fectant and  astringent  solution. 


TUMORS  OF  THE  ORBIT.  14:9 

In  two  cases  where  the  protrusion  was  only  moderate,  I  have 
obtained  a  cure  by  the  use  of  Hepar  and  Silicia,  together  with 
the  packing  of  the  upper  portion  of  the  nose  with  glycerine 
tampons.  Growths,  or  accumulation  of  fluid,  in  the  antrum, 
more  frequently  encroach  upon  the  orbit  than  in  other  direc- 
tions, and  displace  the  floor  of  the  orbit  upwards.  The 
deformity  of  the  side  of  the  face  accompanying  the  distention 
of  the  antrum  will  render  the  location  of  the  lesion  easy. 

Injuries  of  the  Orbit  have  already  been  considered  in  the 
chapter  devoted  to  Injuries  of  the  Eya 


CHAPTEE    YIIL 

DISEASES  OF   THE  LACHEYMAL  APPAEATUS. 

ANATOMY. 

The  parts  which  constitute  the  lachrymal  apparatus  are :  the 
gland  found  at  the  upper  and  outer  side  of  the  orbit,  which 
secretes  the  tears,  with  its  excretory  ducts ;  the  two  canals  near 
the  inner  angle,  into  which  the  fluid  is  received,  and  the  sac, 
continuous  with  the  nasal  duct  through  which  the  tears  pass 
into  the  inferior  meatus  of  the  nose.  The  lachrymal  gland, 
in  minute  structure  similar  to  the  salivary  glands,  is  an  oblong 
flattened  body  about  the  size  of  an  almond,  lodged  in  the 
upper  and  outer  part  of  the  orbit  in  a  slight  depression  in  the 
orbital  plate  of  the  frontal  bone,  to  the  periosteum  of  which 
it  adheres  by  fibrous  bands ;  the  lower  surface  of  the  gland  is 
adapted  to  the  convexity  of  the  eyebalL  The  anterior  part  of 
the  gland  is  separated  from  the  rest  by  a  thin  layer  of  fascia, 
and  is  sometimes  described  as  the  inferior  lachrymal  gland. 
It  is  closely  united  to  the  back  of  the  eyelids  and  presents 
small  lobules  which  open  by  separate  ducts  directly  upon  the 
conjunctiva.  These  ducts  from  both  portions  of  the  gland  are 
very  minute  and  from  twelve  to  fourteen  in  number  opening 
in  a  row  in  the  superior  folds  of  the  conjunctiva  near  the 
temporal  side,  and  the  tear  fluid  is  distributed  over  the  eye 
and  collected  at  the  caruncula  lachrymalis.  On  the  margin 
of  each  lid  (Fig.  55),  near  the  inner  angle  of  the  eye,  is  a 
small  elevation  directed  against  the  eyeball  and  traversed  by 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.  151 

a  minute  aperture,  the  punctum  lackrymalis,  these  openings 
being  the  commencement  of  the  two  canaliculi,  narrow  canals 
which  convey  the  tears  to  the  lachrymal  sac. 

The  lachrymal  sac  and  the  nasal  duct  together  form  a 
passage  about  one  inch  long  by  which  the  tears  reach  the 
nose.     The  lachrymal  sac  presents  an  expanded  portion  rising 

above  the  entrance  of  the  canaliculi, 

^^^^^^^^^  and    is   located    in    the   depression 

^^^^^^^^^^^mwM  formed  by  the  lachrymal  and  supe- 

""^^^^^Sj^^ilt^^^g  rior  maxillary  bones,  being  covered 

^IJ  '' '-il^^J^mSM    posteriorly  by  the  tensor  tarsi,   an- 

^^^^^^^^^^tju/i    teriorly  by  the  tendo  oculi  and  fibres 

^^F^MMw     of  the  orbicularis  muscle.     The  sac 

^  is  composed  of  fibrous  and  elastic 

no.  55.  .  ^ 

tissues  adhering  closely  to  the  bones 
above  mentioned,  and  is  lined  by  a  mucous  membrane  which 
is  very  vascular  and  covered  by  cylindric  epithelium.  The 
duct,  which  is  continuous  with  the  sac,  occupies  the  canal 
{d  Fig.  5G)  formed  for  it  in 
the  superior  maxillary  bone 
and  is  lined  by  the  mucous 
membrane  which  is  continu- 
ous with  that  of  the  nose  and 
sac,  which  partakes  of  the 
character  of  the  periosteum 
and  mucous  membrane,  the 
cylindric  epithelium  of  the 
duct  presenting  ciliated  pro- 
cesses. It  opens  beneath  the 
inferior  turbinated  bone  h  as 
a  narrow  slit,  as  shown  at  e 
in  Fig.  56,  where  the  anterior 
half  of  the  turbinated  bone  '   fig.  56. 

has  been  cut  away.  As  the  sac  joins  the  duct  we  find  the 
mucous  membi:anG  throM-n  into  folds,  and  again  at  its  middle 
portion,  and  at  its  terminus  in  the  meatus.  The  tears  in  their 
passage  over  the  conjunctiva  and  eyeball  are  mostly  evapo- 


152  DISEASES  AND  INJURIES  OF  THE  LYE. 

rated,  the  excess  being  taken  up  by  tlie  pimcta  by  suction 
caused  by  the  minute  muscular  fibres  which  surround  the 
puncta  and  canaliculi,  and  having  reached  the  sac  is  forced  into 
the  duct  by  the  action  of  the  orbicularis  and  the  tendo  oculi 
during  the  action  of  winking,  when  the  fluid  finds  its  way  into 
the  nasal  meatus  by  gravity  aided  by  the  ciliated  epithelium. 

j  DISEASES   OF   THE   LACHKYMAL   GLAND. 

DACRYO-ADENITIS. 

Acute  inflammation  of  the  structure  of  the  lachrymal  gland 
occurs  as  a  result  of  injuries  of  the  upper  and  outer  angle  of 
the  orbit,  is  more  frequent  in  children  than  in  adults,  and 
occurs  more  often  in  women  than  in  men.  It  is  characterized 
by  tenderness,  pain,  local  heat,  swelling  and  rfedness  of  the 
contiguous  parts.  It  is  liable  to  be  mistaken  for  a  periostitis. 
.  It  may  end  in  resolution  or  suppuration ;  if  the  latter  occui'S 
the  pus  is  discharged  through  the  conjunctival  sac,  or  may 
point  on  the  upper  part  of  the  lid ;  in  either  event  a  fistulous 
opening  is  apt  to  remain  for  some  time,  discharging  pus  and 
lachrymal  fluid. 

Dacryo-adenitis  is  more  frequently  of  a  chronic  character 
and  runs  a  very  tedious  course.  The  causes  are  the  same  as 
those  giving  rise  to  the  acute  form.  It  is  usually  manifested 
by  a  gradual  enlargement  of  the  gland  which  can  be  easily 
recognized  by  its  lobulated  border,  but  is  not  readily  distin- 
guished from  morbid  growths  in  the  gland  or  tumors  of  the 
same  region  of  the  orbit.  In  either  form,  if  the  enlargement 
is  great,  the  eyeball  is  displaced  dowTiward  and  inward,  and 
the  superior  folds  of  the  conjunctiva  are  pushed  forward  so  as 
to  lie  between  the  globe  and  the  upper  lid.  The  tumor  is  not 
painful  or  sensitive  to  touch  unless  the  inflammation  is  acute. 

The  accessory  glands  are  sometimes  the  seat  of  suppurative 
inflammation.  The  swelling  and  tenderness  does  not  extend 
over  so  large  an  area  as  when  the  gland  is  involved,  and  on 
everting  the  lids  one  or  two  small,  yellowish  points  are  dis- 
covered in  the  retro-tarsal  folds  above  the  tarsal  cartilage. 


DISEASES  OF  THE  LACHRYMAL  GLAND.  153 

Treatment. — In  the  acute  form,  Aconite  and  Bell,  with  cold 
compresses  may  cause  resolution.  If  suppuration  is  threatened 
then  hot  fomentations  and  poultices  will  be  required,  and  as 
soon  as  pus  is  formed  an  incision  should  be  made  for  its  re- 
lease, as  a  fistulous  opening  is  less  likely  to  remain  than  when 
the  abscess  is  allowed  to  break  spontaneously  through  the  skin. 
Hepar  s.,  Merc,  and  Silicia  are  the  remedies  likely  to  be 
indicated  during  the  suppuration.  In  the  chronic  form  the 
enlargement  may  be  reduced  by  such  remedies  as  Baryta  iod., 
Kali  iod.  and  Phytolacca.  Extirpation  of  the  gland  will 
usually  be  necessary,  the  operative  procedure  being  the  same 
as  that  for  a  tumor  of  the  corresponding  locality.  It  should 
be  borne  in  mind,  however,  that  in  dissecting  out  the  gland  in 
cases  of  hypertrophy,  it  will  be  found  to  extend  very  deep 
into  the  orbit  along  the  roof. 

Functional  diseases  of  the  gland  are  rare,  but  some  cases 
occur  in  which  there  is  hyper-secretion.  In  one  case  a  cure- 
resulted  from  the  internal  use  of  Ignatia  in  a  myope  who  had 
suffered  for  years  from  periodical  attacks  of  lachrymation,  the 
attacks  lasting  from  three  to  four  hours  at  a  time. 

Dacryops. — The  distention  of  one  or  more  of  the  ducts  of 
the  gland  may  occur  from  closure  of  the  conjunctival  opening. 
In  this  case  a  small  bluish  tumor  {dacryops)  the  size  of  a  pea 
will  appear  beneath  the  conjunctiva  on  the  eversion  of  the  lid. 
The  remedy  is  excision  of  a  portion  of  the  cyst  wall. 

TuMOES  OF  THE  Gland. — The  lachrymal  gland  may  be  the 
seat  of  sarcomatous  and  other  morbid  growths  and  cystic 
degeneration.  In  this  case  the  removal  of  the  gland  is 
demanded.  Destruction  or  removal  of  the  gland  does  not 
produce  a  dry  condition  of  the  eye,  because  the  glands  and 
mucous  follicles  of  the  conjunctiva  are  sufficient  to  keep  the 
eye  moist. 

Epiphora,  or  watery  eye,  is  a  term  which  should  be  re- 
stricted to  the  simple  overflow  of  tears  onto  the  cheek  from 
hyper-secretion;  the  term  siillicidiiun  laclirymarum  being 
applied  to  those  cases  where  the  flow  into  the  nose  is  obstructed, 
and  lachrymation  being  an  increase  of  the  tear  fluid  caused  by 


154: 


DISEASES  AND  INJURIES  OF  THE  EYE. 


reflex  action  from  irritation  of  the  ciliary  or  sensitive  nerves, 
as  in  superficial  inflammation  of  the  eyeball  or  irritation  from. 
minute  foreign  bodies  on  tlie  cornea  or  conjunctiva. 

Lacheymal  Strictures,  obstructions  to  the  flow  of  tears, 
are  very  common  and  may  occur  at  any  portion  of  the  lachry- 
mal conduits  and  may  afifect  those  of  both  eyes,  or  of  only  one 
side.  In  the  examination  of  the  case,  the  first  point  to  be 
determined  is  the  condition  and  position  of  the  jpunda.  If 
these  are  closed  or  directed  upward  or  outward,  so  as  not  to 
receive  the  tears,  the  fluid  collects  in  the  palpebral  fissure  and 
drops  over  the  lid  edge  upon  the  cheek.     When  this  condition 


Q 


Goo  Tiemwin  A  Co. 

FIG.  67. 


has  existed  for  a  time,  conjunctivitis,  or  blepharitis  results 
from  decomposition  of  the  fluid  and  subsequent  irritation. 
Occlusion  of  one  punctum  may  cause  little  or  no  annoyance 
from  epiphora,  the  tears  being  carried  off  by  the  other.  If 
troublesome,  however,  the  punctum  may  be  opened  by  means 
of  a  pin,  and  kept  open  by  the  use  of  Anel's  canaliculus  probe. 
(Fig.  57.) 

The  causes  which  give  rise  to  obstruction  at  this  point  are 
usually  chronic  inflammation  of  the  lid  borders  resulting  in 
thickening,  chronic  inflammation  of  the  conjunctiva,  as  granu- 
lar lids  and  paralysis  of  the  facial  nerve  which  causes  a  loss 
of  the  compressing  and  sucking  action  in  winking,  and  a  slight 
falling  away  of  the  lid  from  the  globe.  The  remedy  consists 
in  the  opening  of  the  puncta  and  division  of  the  canaliculus, 
except  in  paralytic  cases. 

The  operation  of  slitting  the  canaliciihis  is  performed  on  the 
lower  canaliculus  by  dilating  the  punctum  by  a  fine  probe- 
pointed  knife,  as  Weber's  (Fig.  58),  or,  if  the  opening  is  much 
narrowed  or  occluded,  the  lachrymal  eminence  can  be  dis- 
covered with  a  little  care,  and  the  point  of  a  needle  or  pin 
inserted,  and  the  punctum  stretched  so  that  the  probe  point  of 


LACHRYMAL  STRICTURES,  155 

the  knife  may  be  introduced.  The  patient  is  seated,  and  the 
operator  stands  behind  and  supports  the  head  on  the  chest;  the 
lower  lid  is  drawn  tightly  outward  and  slightly  everted  by 
the  thumb,  the  point  of  the  canaliculus  knife  introduced  into 
the  punctum  in  a  vertical  direction  and  then  turned  hori- 
zontally and  passed  through  the  canaliculus,  the  cutting  edge 
being  directed  slightly  inward  and  upward  until  the  inner 
wall  of  the  lachrymal  sac  is  reached,  and  as  the  handle  of  the 
knife  is  raised  towards  the  median  line  of  the  head  the  canali- 
culus is  divided  to  its  entrance  into  the  sac.  The  line  of  the 
incision  should  lie  at  the  inner  edge  of  the  free  margin  of  the 


FIG.  58. 


lid,  as  in  this  direction  the  opened  canaliculus  more  readily 
receives  the  tears  to  convey  them  to  the  nose.  This  must  be 
kept  open  by  the  daily  passage  of  a  small  probe  until  a  gutter 
remains  instead  of  the  closed  canal.  In  paralytic  cases  open- 
ing the  upper  canaliculus  affords  better  chances  for  relief.  In. 
this  case  the  canaliculus  knife  is  introduced  into  the  punctum, 
the  upper  lid  being  put  on  the  stretch,  and  the  knife  passed 
upward  and  inward  and  the  canaliculus  split  upon  its  edge. 

Causes  of  Strictuee.— The  causes  of  lachrymal  stricture 
are  various ;  the  presence  of  foreign  bodies  may  excite  inflam- 
mation, wounds  and  the  resulting  cicatrix,  and  the  extension  o£ 
chronic  catarrhal  conditions  of  the  nose  and  conjunctiva.  Inju- 
ries of  the  lids  in  the  region  of  the  canaliculi  usually  cause 
stricture  and  require  slitting  of  the  canaliculus.  Foreign 
bodies  may  fill  the  canaliculus  and  thus  cause  obstruction. 
These  may  be  hairs,  cilia,  chalky  deposits,  or  fungous  growtha 
of  leptothrix ;  the  former  should  be  removed,  and  if  the  latter 
cannot  be  pressed  out  the  canaliculus  should  be  opened  up  and 
the  bluish  mass  removed,  and  injections  of  boracic  or  weak 
carbolic  acid  used  until  all  vestiges  of  the  vegetation  have  dis- 


136  DISEASES  AND  INJUBIES  OF  THE  EYE. 

■appeared.  The  most  frequent  cause  of  obstruction  to  the 
lachrymal  flow  are  strictures  of  the  lachrymal  or  nasal  duct. 

Symptoms  of  Steicture. — Besides  the  overflow  there  is 
frequently  a  small  tumor-like  prominence  of  the  lachrymal  sac 
to  the  nasal  side  of  and  just  below  the  inner  canthus,  which  is 
termed  mucocele.  (Fig.  64).  Pressure  upon  this  causes  a  filling 
of  the  inner  canthus  with  viscid  mucus  or  muco-pus,  mixed 
'with  tears,  through  the  canaliculi  and  puncta. 

Varieties  of  Stricture. — Strictures  may  be  of  three 
Tarieties,  mucous,  fibrous  and  ho7iy.  The  mucous  form  is  occa- 
eioned  by  folds  of  the  mucous  membrane  lining  the  sac  becom- 
ing thickened  by  inflammatory  action  extending  from  the 
nose  and  causing  a  union  of  the  opposite  walls,  either  at 
ihe  nasal  opening,  at  the  junction  of  the  nasal  and  lachrymal 
■ducts,  or  in  the  lachrymal  sac.  In  this  case,  the  application  of 
glycerine  by  a  camel's  hair  brush,  or  a  cotton  tampon  saturated 
'with  glycerine,  to  the  parts  about  the  middle  turbinated  bone 
of  the  affected  side,  will  relieve  the  hypersemia  and  cause 
■a  re-opening  of  the  duct  in  many  cases.  If  the  union  of  the 
surfaces  is  strong,  the  operative  procedures  necessary  for  the 
fibrous  form  will  be  demanded.  The  fibrous  variety  results 
from  long-continued  inflammation,  more  or  less  chronic,  which 
implicates  the  outer,  fibrous,  layer  of  the  duct.  An  ulcerative 
process  is  often  present  in  these  cases  and  several  fibrous  bands 
•of  various  widths  in  different  portions  of  the  duct  result. 
These  strictures  may  be  single  or  multiple  and  may  be  found 
in  any  portion  of  the  duct  or  lachrymal  sac.  Bony  strictures 
arise  from  slow  inflammatory  affections  of  the  f)eriosteum 
which  may  cause  a  filling  up  of  the  canal  at  some  portion,  or  its 
more  or  less  complete  obliteration.  The  most  frequent  seat 
of  these  strictures  is  at  the  junction  of  the  lachrymal  and  nasal 
ducts.  The  bone  is  often  denuded  of  the  periosteum  and  feels 
Toughened  under  the  probe. 

Treatment. — Bony  strictures  are  usually  forlorn  cases,  as 
ihey  are  impermeable.  Various  operations  have  been  pro- 
posed and  attempted  for  the  relief  of  these  cases,  but  without 
satisfactory  results.     There  is  a  field  here  for  the  application 


LACHRYMAL  STRICTURES— TREATMENT. 


157 


of  the  internal  remedy.  In  one  case,  due  to  osseous  closure, 
the  administration  of  Hecla  lava,  6x  trituration,  caused  suffi- 
cient absorption  to  allow  of  the  passage  of  a  No.  2  Bowman's 
probe.  In  cases  of  caries,  Silicia,  Kali  iod.  and  other  reme- 
dies may  improve  the  condition.  In  the  treatment  of  all 
forms  of  lachrymal  obstruction,  the  first  thing  to  be  done  is  to- 
improve  the  condition  of  the  mucous  membrane  lining  tha 
passages  by  the  use  of  such  remedies  as  Petrol.,  Arg.  nit, 
Stannum,  Pulsatilla,  Silicia  and  Merc,  when  the  puncta  or 
canaliculi  are  not  at  fault.  The  patient  should  be  directed  to- 
press  gently  upon  the  mucocele  as  frequently  as  it  appears, 
and  having  removed  the  accumulation  from  the  inner  canthus, 
a  lotion  of  borax  gr.  x  ad  fsi,  calen- 
dula 0  gtt.  XX  ad  f  51,  or  boracic  acid  gr. 
V  ad  fsi  of  water.  If  the  canal  does 
not  become  patent  after  such  treatment 
has  been  employed  or  acute  inflam- 
matory symptoms  supervene,  then  the 
canaliculus  must  be  slit  up  and  the 
stricture  divided  and  the  probe  intro- 
duced. (Pig.  59)  Por  the  division 
of  the  stricture  and  the  passage  of  tha 
probe  the  canaliculus  is  to  be  slit  up 
in  the  manner  already  described  and 
the  stricture  incised  with  either  a 
"Weber  (Pig.  58),  or  Bowman,  canaliculus  knife,  although 
they  are  usually  too  slender  to  use  with  safety.  The  better 
method  is  to  open  the  canaliculus  and  holding  a  small  probe, 
either  Bowman's  No.  1  or  2  (Pig.  61),  parallel  with  the  mar- 
gin of  the  lower  lid,  the  point  is  introduced  into  the  opened 
canaliculus  and  carried  inward  until  it  rests  upon  the  lach- 
rymal bone;  if  puckering  of  the  lid  at  the  inner  canthus 
results,  the  opening  of  the  canaliculus  into  the  sac  has  not 
been  divided,  and  the  opening  must  be  made  larger ;  the  probe 
is  then  brought  into  a  vertical  position  and  the  attempt  made 
to  follow  the  direction  of  the  duct,  which  is  downward,  out- 
ward and  slightly  backward.     The  curve  of  the  duct,  however, 


FIG.  59. 


158  DISEASES  AND  INJURIES  OF  THE  EYE. 

Taries  somewhat  in  different  individuals  and  the  particular 
curve  must  be  determined.  If  the  stricture  is  not  dense, 
moderate  pressure  may  cause  sufficient  dilatation  of  it  to  allow 
the  passage  of  the  probe.  The  most  important  point  to  be 
observed  is  that  the  probe  engages  in  the  upper  part  of  the 
nasal  duct  in  the  opening  in  the  superior  maxillary.  The 
danger  is  that  the  probe  may  pass  over  the  edge  of  the  open- 
ing to  the  inner  side  and  a  false  opening  be  made  into  the 
nose,  or  to  the  outer  side,  and  hemorrhage  or  emphysema  of 
the  orbital  tissue  result  from  a  laceration  of  the  sac  at  this 
point.  The  probe  passed  into  the  canal  enables  us  to  locate 
the  position  and  determine  the  kind  of  stricture  to  be  dealt 
with.     If  the  stricture  is  not  separated  by  the  passage  of  the 


probe,  and  is  found  not  to  be  bony,  it  may  be  divided  by  the 
Agnew,  Knapp,  or  Noyes,  knife  with  a  pliable  shank,  intro- 
duced in  the  same  manner  as  a  probe  to  the  seat  of  stricture 
when  it  is  divided  by  passing  it  through  it ;  or  the  operation 
of  Stilling  which  is  made  with  a  much  stronger  knife  {Fig.  60.) 
which  is  passed  down  in  the  same  manner,  and  pushed 
through  the  stricture,  and  then  partly  withdrawn  and  turned 
in  other  directions  and  pushed  down  again  until  the  stricture 
is  divided  in  several  places.  There  is  generally  bleeding 
from  the  nose  which  is  an  indication  that  an  opening  has  been 
made  through  the  stricture.  The  immediate  passage  of  the 
probe  will  depend  upon  the  ability  of  the  patient  to  sustain 
further  pain.  If  an  anaesthetic  has  been  used,  my  practice 
is  to  pass  as  large  a  probe  as  possible  and  allow  it  to  remain 
for  a  few  moments  while  the  patient  is  recovering  from  the 
anaesthetic.  If  it  is  not  desirable  to  probe  the  canal  at  the 
time  of  division  of  the  stricture,  the  patient  is  directed  to 
apply  cold  dressings  to  the  eye,  and  take  Aconite  internally  for 
twenty -four  hours  when,  if  the  parts  are  not  very  painful,  the 
probe  may  be  inserted.     The  canaliculus  must  be  kept  from 


LACHRYMAL  STRICTURES— TREATMENT. 


159 


healing  by  the  daily  passage  of  the  probe,  and  this  should  be 
introduced  the  full  length  two  or  three  times  a  week,  allowing 
it  to  remain  ten  or  fifteen  minutes  at  each  sitting.  In  regard 
to  the  maximum  dilation  which  should  be  produced  by  probes, 


FIG.  61. 


surgeons  differ ;  except  in  rare  cases,  I  have  found  the  No.  8 
of  Bowman  to  suffice;  occasionally  benefit  may  be  derived 
from  a  Theobold  No.  10,  where  there  is  a  decided  tendency  to 
recurrence  of  the  stricture,  though  I  deprecate  the  forcible 


FIG,  62. 


distention  by  such  large  probes,  as  they  are  usually  produc- 
tive of  more  harm  than  good.  The  Bowman  probes  (Fig  61), 
which  come  in  sets  of  four,  numbered  from  1  to  8,  are 
straight  when  received  from  the  instrument  makers,  and  should 


be  curved  to  correspond  with  Weber's  (Fig.  62),  which  is  a 
conical  probe  increasing  rapidly  in  diameter  from  the  point; 
but  this  cur\'e  will  also  have  to  be  modified  to  suit  the  sinu- 
osities of  the  duct  in  individual  cases.  In  some  cases  the 
bulbous  pointed  probes  of  Williams  (Fig.  63)  will  be  found 
very  useful. 


160  DISEASES  AlW  INJURIES  OF  THE  EYE. 

Electrolysis. — In  the  Transadimis  of  the  Am.  Horn.  Oph. 
and  Otol.  Society  for  1879,  I  advocated  the  use  of  the  gal- 
vanic current  for  the  solution  of  lachrymal  strictures,  as  the 
continued  use  of  it  in  the  treatment  of  obstinate  cases  had 
been  eminently  successful  in  my  hands.  In  the  records  of 
eighty-seven  cases  treated  in  this  manner,  I  find  nothing  dis- 
tinctive, as  regards  the  cases.  Many  of  them  had  already 
been  subjected  to  Bowman's  or  Stilling's  operation  and  the 
various  methods  of  injection.  They  were  all  chronic  cases 
with  the  canaliculi  slit  up,  and  many  of  them  had  had  opera- 
tions upon  the  stricture  previously  without  permanent  result. 
The  majority  were  women  on  whom  it  was  difficult  to  use  the 
knife  or  even  the  probe,  from  hyper-sensitiveness,  but  who 
submitted  without  trouble  to  the  use  of  electricity,  although 
accompanied  with  more  or  less  pain.  For  the  treatment  of 
these  cases  insulated  probes  of  the  size  ordinarily  used  are 
required.  The  points  of  the  electrodes  should  be  olive- 
shaped,  and  the  insulation  smooth,  hard  and  pliable,  not  caus- 
ing any  increase  in  the  calibre  of  the  probe,  and  extending  to 
within  2  mm.  of  the  point.  The  electrodes  for  the  ducts  must 
first  be  introduced  into  the  sac  down  to  the  seat  of  stricture 
and  then  connected  with  the  negative  pole  of  the  battery  by 
an  insulated  wire.  The  number  of  cells  must  be  determined 
by  the  operator  in  individual  cases,  and  depends  upon  the 
strength  of  the  battery  and  the  position  of  the  positive  pole, 
whether  in  the  hand  or  upon  the  cheek  of  the  patient  Five 
to  fifteen  Siemen's  and  Halske's  small  cells  are  generally  suffi- 
cient for  the  purpose.  Great  care  must  be  exercised  here  as 
elsewhere  not  to  use  a  current  of  such  strength  as  to  produce 
an  eschar.  The  length  of  time  and  the  frequency  of  the 
sittings  must  depend  upon  the  amount  of  irritation  produced. 
In  the  cases  treated,  the  current  was  used  from  two  to  three 
minutes  at  a  time  and  at  intervals  of  two  or  three  days  until  I 
was  able  to  pass  the  largest  probe,  when  the  sittings  occurred 
only  every  week  or  two  weeks.  When  the  strictures  are  very 
firm  and  numerous  I  have  made  several  applications  before 
passing  through  them,  afterwards  using  larger  electrodes  until 


LACHRYMAL  STRTCTURES— TREATMENT.  161 

the  largest  lachrymal  probes  were  passed  without  difficulty.  The 
solution  of  the  strictures  was  not  the  only  good  result  attained 
by  the  use  of  the  galvanic  current  in  these  cases,  as  the  im- 
proved condition  of  the  mucous  membrane  was  apparent  after 
a  few  applications,  by  the  prompt  relief  of  the  blennorrhcea. 

AVhen  the  patient  resides  at  a  distance  and  cannot  remain 
for  sufficient  time  to  produce  a  cure,  if  the  duct  tolerates  the 
probe  well  a  lead  wire  probe  may  be  introduced  and  allowed 
to  remain  for  some  weeks,  the  upper  end  of  the  wire  being 
bent  over  and  turned  so  as  to  lie  in  the  slit  canaliculus  or  pro- 
ject one  eighth  of  an  inch  on  the  side  of  the  nose,  the  patient 
being  directed  to  remove  it  if  it  should  become  uncomfortable. 
During  the  time  that  the  probing  is  carried  on,  the  sac  and 
duct  must  receive  attention  tending  to  improve  their  condition. 
The  close  prescription  of  remedies  and  the  use  of  injections 
with  a  lachrymal  syringe,  after  the  passage  of  the  probe,  wdll 
materially  hasten  the  cure.  In  the  use  of  the  syringe,  the 
barrel  having  been  filled  with  the  lotion,  the  point  of  the 
syringe  is  passed  into  the  duct  in  the  same  manner  as  a  probe, 
the  piston  pushed  down  and  the  fluid  forced  into  the  nose 
whence  it  drops,  as  the  patient  leans  forward,  into  a  cuspidor 
conveniently  placed.  Many  lotions  have  been  recommended 
for  use  in  this  way,  and  some  may  possess  certain  advantages 
in  special  cases.  The  most  useful  for  the  majority  of  cases 
will  be  boracic  acid  gr.  iv  ad  fsi.  Injections  of  tannic  acid  and 
glycerine  gr.  xv  ad  3  j  diluted,  or  arg.  nit.  gr.  i-ii.  ad  f  3  j  may  be 
also  used.  Under  this  treatment  the  discharge  diminishes  and, 
in  a  short  time,  the  probe  becomes  necessary  only  at  longer 
intervals,  but  will  have  to  be  continued  for  a  long  time  even 
after  an  apparent  cure  has  been  accomplished.  If  all  treat- 
ment fails,  or  if  the  duct  is  absolutely  impermeable  to  the 
probe,  the  sac  may  be  destroyed  by  opening  it  freely  just 
below  the  inner  canthus,  and  cauterizing  the  interior  by  the 
galvanic  cautery,  chloride  of  zinc  or  nitrate  of  silver,  but  the 
results  are  by  no  means  satisfactory.  The  comfort  of  the 
patient  may  be  more  readily  obtained  by  excision  of  the  lach- 
rymal gland. 
11 


162  DISEASES  AND  INJURIES  OF  THE  EYE. 

DAORTO-CYSTI TIS. 

Causes. — Acute  inflammation  of  tlie  lachrymal  sac  and  duct 
occurs  by  extension  of  diseases  from  the  conjunctiva  through, 
the  canaliculi,  or  as  incidental  to  chronic  catarrhal  conditions 
of  the  nostril  or  of  the  lachrymal  duct,  and  the  closure  of  the 
canaliculi  in  cases  of  stricture  of  the  duct  with  distention  of 
the  sac. 

Symptoms. — The  attack  may  be  preceded  by  a  chill,  and  is 
attended  with  severe  pain,  tenderness  and  slight  swelling  of 
the  sac,  often  accompanied  by  considerable  fever  and  constitu- 
tional disturbance.  The  condition  is  recognized  by  the  pres- 
ence of  a  small,  hard  and  painful  tumor  at  the  nasal  side  of 
the  inner  can  thus,  which,  as  the  inflammation  progresses,  be- 
comes tense  and  shining,  and  the  swelling  extends  to  the 
cheek  and  eyelids,  the  latter  becoming  so  oedematous  as  to 
prevent  their  being  opened.  The  whole  side  of  the  face  may 
become  involved  in  the  phlegmonous  inflammation  and  the  at- 
tack may  be  mistaken  for  one  of  facial  erysipelas.  If  the 
inflammatory  process  is  unchecked,  an  abscess  forms  in  the 
sac  and  fluctuation  may  be  felt;  the  pus  points  outward,  and, 
if  left  alone,  discharges  through  an  opening  in  the  skin ;  after 
a  short  time  the  swelling  subsides,  the  canaliculi  again  open 
and  the  parts  return  to  their  normal  condition.  It  more  often 
happens  when  the  disease  is  allowed  to  run  its  course  that  it 
terminates  in  a  lachrymal  Jishila;  the  tears  which  enter  the 
sac  again  pass  out  through  the  opening  made  by  the  abscess, 
mixed  with  mucus  and  pus.  This  may  close  after  a  time  and 
abcesses  frequently  recur.  Occasionally  caries  or  necrosis  of 
the  lachrymal  bone  results  in  syphilitic  or  scrofulous  patients. 

Treatment. — At  the  commencement  of  the  inflammation  it 
may  be  possible  by  the  use  of  cold  compresses,  or  ice  bags, 
together  with  the  internal  administration  of  Aeon.,  Bell.,  or 
Yerat.  vir.  to  abort  the  attack.  The  surer  means  of  doing  so, 
however,  lies  in  the  immediate  slitting  up  of  one  or  both 
canaliculi,  before  the  oedema  of  the  lids  has  become  so  great 
as  to  make  it  impossible.     The    divided  canaliculi   will  give 


DACRYO-CYSTO-BLENNORRHCEA. 


163 


vent  to  the  imprisoned  contents  of  the  sac,  and  the  inflamma- 
tory symptoms  will  subside  rapidly  with  the  treatment  above 
indicated.  As  soon  as  pus  forms  in  the  sac,  the  temperature 
of  the  topical  applications  must  be  changed  and  hot  fomenta- 
tions of  calendula  decoction  or  diluted  tincture  of  veratrum 
Tir.  (gtts  XX  ad  fsi)  applied  continuously,  together  with  the 
internal  administration  of  Hepar,  Puis,  or  Silicia  as  may  be 
indicated,  and  as  the  swelling  of  the  lids  is  usually  too  great 
to  allow  of  the  opening  of  the  canaliculi  without  an  anaesthetic, 
a  free  incision  must  be  made  with  the  bistoury  directly  into 
the  sac  and  the  pus  allowed  to  escape ;  the  hot  compresses  may 
be  continued  for  twenty-four  or  forty-eight  hours  when  the 
acute  symptoms  have  about  subsided.  As  soon  as  this  result 
has  been  attained,  an  effort  must  be  made  to  close  the  fistulous 
opening  which  will,  usually,  occasion  little  trouble,  if  a  free 
passage  to  the  nose  is  established  by  the  removal  of  any  strict- 
ure of  the  duct  which  may  be  present,  with  the  probe  or  knife, 
In  the  treatment  of  the  lachrymal  fistula,  after  having  re- 
moved any  obstruction  to  the  flow  of  tears  through  the  lachry- 
mal duct,  the  edges  of  the  fistulous  opening  should  be  touched 
with  nitrate  of  silver.  If  polypoid  granulations  spring  from 
the  opening,  benefit  will  be  derived  by  filling  it  with  alumen 
exsiccatum  pulv.  In  some  cases  the  edges  of  the  fistulous 
opening  will  require  paring  and  the  subsequent  application  of 
pressure  at  the  opening,  which  may  be  made  by  the  applica- 
tion of  a  cork  on  the  end  of  a  spring  band  which  is  riveted  to 
a  band  passing  round  the  forehead.  Certain  remedies  have 
been  reported  as  having  cured  cases  of  lachrymal  fistula  with- 
out operative  interference,  but  in  my  hands,  after  a  thorough 
trial,  have  given  no  result. 

DACRYO-CTSTO-BLENNORRH(EA. 

Catarrhal  inflammation  of  the  lachrymal  sac  and  duct  is  gen- 
erally a  secondary  affection  due  to  an  extension  of  the  catar- 
rhal inflammation  from  the  nose  or  conjunctiva,  and  rarely 
comes  for  treatment  until  after  the  duct  has  been  obstructed. 


164 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Symptoms. — At  first  there  is  a  slight  uneasiness  at  the  inner 
canthus  to  which  little  attention  is  paid.  Exposure  to  cold  or 
•windy  weather  causes  the  tears  to  run  down  the  cheeks.  This 
condition  of  things  may  last  for  months,  the  flow  of  tears  be- 
comes more  constant  and  requires  the  frequent  application  of 
the  handkerchief  during  the  day.  In  course  of  time  a  thick 
mucous  discharge  appears  at  the  inner  canthus;  this  changes- 
to  a  purulent  secretion,  and,  if  neglected,    the  disease    may 

progress  and  gradually  distend 
the  lachrymal  sac.  The  mucous 
membrane  lining  the  sac  be- 
comes swollen  and  all  its  layers 
hypertrophied,  the  nasal  portion 
of  the  duct  occluded  by  the 
formation  of  a  stricture,  and 
the  sac  gradually  fills  and  be- 
comes distended  and  presents 
no- 64.  as  a.  mucocele,  (Fig  64).     The 

patient  soon  learns  that  by  pressure  upon  the  sac  the  con- 
tents are  forced  down  into  the  nose  or  into  the  eye ;  in  either 
event,  the  sac  is  emptied  and  a  repetition  of  this  as  often  as 
the  sac  fills,  affords  considerable  relief.  The  disease  is  slow 
in  its  progress  and  for  a  long  time  causes  but  moderate  annoy- 
ance, but  after  the  mucocele  has  formed,  if  the  sac  is  not  con- 
stantly emptied,  the  accumulated  secretion  decomposes  and 
becomes  irritating,  and  when  brought  in  contact  with  the  con- 
junctiva brings  on  an  attack  of  conjunctivitis.  The  inception, 
of  cold  in  this  condition  causes  an  increased  secretion,  further 
swelling  and  an  attack  of  phlegmonous  inflammation  of  the 
sac ;  and  abscess  or  fistula  follow. 

In  general  the  disease  is  very  protracted  and  in  spite  of  the 
best  and  most  patient  treatment  proves  obstinate  and  intracta- 
ble. In  the  majority  of  cases  the  progress  under  treatment 
is  so  slow  that  patients  become  discouraged,  or  are  unwilling 
to  take  the  time  for  proper  treatment,  and  the  surgeon  does 
not  have  the  opportunity  to  continue  effectual  treatment  for  a. 
sufficient  length  of  time  to  bring  about  a  cure. 


DACRYO-CYSTO-BLENNORRHCEA— TREATMENT.  165 

Tlie  presence  of  any  lachrymal  disease  contra-indicates  any 
operations  upon  the  cornea  or  iris,  owing  to  the  great  danger 
of  infection  of  the  wound  from  the  purulent  secretions,  Tience 
it  follows  that  all  cases  requiring  operations  for  cataract  or 
iridectomy  demand  a  previous  cure  of  the  lachrymal  trouble. 

Treatment. — Where  the  catarrhal  condition  is  dependent 
upon  stricture  of  some  portion  of  the  lachrymal  passages,  the 
first  indication  for  treatment  lies  in  the  relief  of  the  stricture 
in  the  manner  already  described.  Patients  will  not  always 
consent  to  the  most  rational  and  rapid  methods  of  relief  in 
these  cases.  They  should,  however,  be  directed  to  keep  the 
sac  empty  by  firm,  slow  pressure  upon  it  ynih.  the  tip  of  the 
finger,  so  as  to  force  the  accumulation  into  the  nose  or  through 
the  canaliculi  into  the  inner  canthus  where  it  is  absorbed  by 
gentle  pressure  with  the  handkerchief,  and  immediately  after- 
wards a  few  drops  of  a  solution  of  borax  (sodsB  biboratis  gr,  v. 
— X  ad  ill)  may  be  dropped  into  the  inner  canthus  and  on  the 
relief  of  the  pressure  of  the  finger  made  to  enter  the  sac.  To 
keep  the  irritation  at  the  minimum,  the  sac  must  not  be  allowed 
to  become  distended,  and  all  rubbing  of  the  lids  should  be 
avoided.  Care  should  also  be  taken  to  avoid  exposure  of  the 
eyes  to  cold  winds  or  over-taxation.  The  condition  of  the 
mucous  membrane  of  the  eyes  must  also  receive  attention,  as 
the  improvement  of  the  nasal  catarrh,  or  ozgena,  oftentimes 
results  in  a  marked  improvement  of  the  condition  of  the  sac. 
The  internal  remedies  which  have  proved  of  value  in  the 
treatment  of  catarrhal  and  blennorrhoeal  conditions  of  the 
lachrymal  sac  are: 

Aconite. — Indicated  when  the  mucous  membrane  presents 
the  same  hypertrophied  condition  which  was  present  in  the 
conjunctival  affection  which  precedes  or  accompanies  it. 

Euphrasia. — Indicated  in  similar  conditions  to  Aconite  and 
frequently  follows  the  latter  when  the  discharge  becomes  thick, 
yellow  and  acrid. 

Pulsatilla  and  Calc.  carh. — When  there  is  a  profuse,  thick 
and  bland  discharge.     The  concomitants  deciding  the  choice. 

Argent  nit. — Catarrh  of  the  lachrymal  sac,  when  the  dis- 


166  DISEASES  AND  INJURIES  OF  THE  EYE. 

charge  is  profuse  and  the  caruncle  and  semi-lunar  folds  appear 
red  a:gd  inflamed. 

Petroleum. — This  remedy  has  a  marked  action  upon  the 
mucous  membrane  of  the  lachrymal  sac  when  the  obstruction 
is  due  to  thickening  of  the  mucous  folds.  The  temporary 
stricture  is  often  relieved  by  it  without  the  necessity  of  opera- 
tive interference. 

CaZewcZwZa.— Particularly  useful  in  obstinate  cases,  when  the 
blennorrhoea  continues  after  the  duct  has  been  opened,  and  the 
stricture  tends  to  re-form,  and  should  be  applied  locally,  as 
well  as  given  internally. 

Stannum. — Eelieves  some  cases  of  blennorrhoea  of  the  sac, 
where  there  is  a  profuse,  yellowish-white  discharge  with  sharp 
pain  or  itching  of  the  inner  canthus,  particularly  at  night. 

Arsen.  iod. — Proves  useful  in  curing  obstructions  of  the  duct 
dependent  upon  acute  inflammation  and  swelling  of  the  nasal 
mucous  membrane.  It  may  be  suitable  in  those  cases  of 
blennorrhoea  of  the  duct  accompanied  by  a  dry  ulcerated  condi- 
tion of  the  nostrils. 

Hepar  siilpli. — In  inflammatory  conditions  of  the  sac  with 
sensitiveness  to  touch,  and  free  discharge  of  pus  with  or  with- 
out an  opened  canaliculus. 

Mercurius. — The  discharge  is  thin,  acrid,  and  often  excori- 
ates the  lid  margins,  or  the  cheek  where  the  overflow  comes  in 
contact  with  it. 

Silicia. — There  is  a  bland,  whitish  discharge  of  decomposed 
mucous  and  pus  from  the  distended  sac  after  the  canaliculus 
has  been  opened  and  probing  begun.  It  may  be  also  indicated 
in  the  recurrent  inflammatory  attacks  of  old  cases  of  blennor- 
rhoea of  the  sac. 

Many  other  remedies  have  been  recommended  and  have 
■undoubtedly  been  of  service  in  improving  the  condition, 
as  Arum  tr.,  Aurum  mur..  Bell.,  Calc.  Cup.,  Alum.,  Hydrast., 
JEluor.  ac,  Kali  iod.,  Nat.  mur.,  Nux,  Sulphur  and  Zinc,  sulph. 


CHAPTEE  IX. 

DISEASES  OF  THE  LIDS. 

ANATOMY. 

The  eyelids  are  movable  portions  of  integument,  strength- 
ened towards  their  free  margins  by  a  thin  lamina  of  dense 
fibrous  tissue ;  externally  they  are  continuous  with  the  cuticle 
of  the  forehead  and  face,  internally  lined  by  the  conjunctiva 
which  is  reflected  onto  the  eyeball.  The  upper  lid  is  larger 
and  more  movable  than  the  lower,  the  whole  of  the  cornea 
being  covered  by  it  when  closed,  and  it  is  chiefly  by  the  ele- 
vation of  the  upper  lid  that  the  eye  is  opened,  the  movement 
being  effected  by  the  levator  palpebrse,  which  arises  in  conjunc- 
tion with  the  four  recti  muscles  at  the  apex  of  the  orbit, 
and  passes  along  the  roof  of  the  orbit  to  be  inserted  by  a 
broad  tendon-like  expansion  into  the  tarsus  of  the  lid.  At  the 
outer  and  inner  angles  (canthi)  the  eyelids  are  united,  the 
interval  between  the  canthi  being  termed  the  fissura  palpe- 
brarum, and  on  its  size  depends  the  apparent  size  of  the  eye. 
The  edge  of  each  lid  is  flattened,  except  at  the  inner  canthus 
where  it  becomes  somewhat  rounded  and  changed  in  direction; 
at  this  point  on  each  lid  is  found  a  conical  elevation,  the  pap- 
illa lachrymalis,  upon  the  top  of  which  is  found  a  minute 
opening,  the  punctum  lachrymalis. 

Throughout  the  whole  extent,  except  at  the  inner  canthus, 
the  lids  are  applied  by  the  orbicularis  muscle  directly  to  the 
surface  of  the  eyeball. 

167 


168 


DISEASES  AND  INJURIES  OF  THE  EYE. 


The  skin  covering  the  lids  is  thin  and  more  delicate  than  the 
contiguous  cuticle,  presenting  fine  downy  hairs,  sudoriferous 
glands,  and  at  its  free  margin  where  the  cilia  present,  it  joins 
the  conjunctiva  lining  the  inner  surface. 

Beneath  the  skin  are  found  the  fibres  (  h  Fig.  65)  of  the 
orbicularis  muscle  which  closes  the  eyelids,  loose  connective 
tissue,  and  the  dense  fibrous  plates  (/  Fig.  65)  which  are 
termed  the  tarsal  cartilages  or  tarsi, 
and  are  continuous  with  a  thin  fibrous 
membrane  (Z  Fig.  65)  which  attaches 
the  lids  to  the  margin  of  the  orbit,  the 
tarso-orbital  fascia. 

The  upper  tarsus  is  half  oval  in  form, 
the  lower  thinner,  narrower,  and  more 
round,  both  giving  the  shape  and  firm- 
ness to  the  lids. 

On  the  posterior  surface  immediately 
beneath  the  conjunctiva  of  the  lids,  in 
grooves  in  the  tarsi,  are  the  meibomian 
glands  (d  Fig.  65),  thirty  to  forty  in 
^^•^-  the  upper   lid,    and   twenty   to   thirty 

in  the  lower;  they  are  modified  sebaceous  glands,  which  open 
by  minute  orifices  upon  the  free  margin  of  the  lids,  discharg- 
ing a  thin  fatty  secretion  which  tends  to  prevent  adhesions 
of  the  lids. 

The  eyelashes  or  cilia  are  strong,  short,  curved  hairs 
arranged  in  two  rows  along  the  margin  of  the  lids  at  the  line 
of  the  union  of  the  cuticle  and  conjunctiva.  The  upper  lashes 
are  more  numerous  and  stronger  than  the  lower  and  curved  in 
opposite  directions ;  at  the  inner  canthus  they  are  weaker  and 
more  scattered.  Each  cilia  drops  from  its  follicle  every  ninety 
days  and  a  new  one  takes  its  place. 


DISEASES  OF  THE  LIDS. 


The  various  tissues  which  form  the  lids  may  be  primarily 
affected  by  an  inflammatory  process  and  tissue  change,  or  they 


DISEASES  OF  THE  LIDS— BLEPHARITIS  ACUTA.  169 

may  become  involved  secondarily  by  the  inflammation  of  adja- 
cent parts,  as  the  cuticle  of  the  face,  the  conjunctiva,  eyeball, 
or  orbital  bones,  and  oedema,  blepharitis,  or  abscess  follows. 

CEdema  of  the  lids  is  a  frequent  accompaniment  of  severe 
inflammations  of  the  conjunctiva,  cornea,  or  iris  and  subsides 
as  the  exciting  conditions  improve.  It  is  frequently  due  to 
constitutional  causes  in  persons  of  a  feeble  or  delicate  habit 
who  have  some  heart  or  kidney  affection,  and  occurs  usually 
duriner  the  night.  The  connective  tissue  of  the  lids  becomes 
infiltrated  with  serum  and  the  skin  is  distended  and  pits  on 
pressure.  Slight  injuries,  as  the  bite  of  insects,  may  be  the 
occasion  of  the  swelling.  In  cases  which  arise  without  appa- 
rent cause,  the  internal  administration  of  Arsen.,  Apis,  Ehus 
tox.,  or  Kali  carb.,  as  the  general  symptoms  may  decide,  is  suf- 
ficient to  relieve  the  condition,  while  the  swelling  is  reduced 
still  more  rapidly  by  the  application  of  a  compress  bandage. 

Emphysema  of  the  lids  is  due  to  blows  or  falls,  with  rupture 
of  the  mucous  membrane  from  the  contusion.  It  is  frequently 
an  indication  of  fracture  of  the  nasal  bones,  or  of  the  eth- 
moidal or  frontal  cells.  The  skin  is  puffed  and  gives  a  crepit- 
ant sound  on  pressure.  A  compress  bandage  and  rest  is  all  that 
is  required  for  its  relief, 

BLEPHARITIS  ACUTA. 

Acute  inflammation  of  the  connective  tissue  of  the  eyelids,  or 
abscess,  arises  from  injuries  to  the  lid,  or  supervenes  upon  ery- 
sipelas of  the  lids,  and  occurs  frequently  in  strumous  children 
without  apparent  cause.  The  upper  lid  is  more  commonly 
affected.  The  disease  comes  on  rapidly  with  great  redness, 
heat  and  swelling  of  the  lids,  and  sensitiveness  to  touch.  The 
B^velling  is  hard,  usually  at  one  point,  which  rapidly  increases 
in  size  until  the  lid  is  enormously  distended;  soon  fluctuation 
is  discernible  and  the  skin  thins  and  becomes  yellowish,  at 
some  point  ulcerates  and  a  large  amount  of  thick  creamy  pus 
is  discharged,  and  the  swelling  and  inflammation  rapidly  sub- 
side.    Occasionally  the  abscess  may  discharge  through  the 


ITO  DISEASES  AND  INJURIES  OF  THE  EYE. 

conjunctival  surface  of  the  lids.  If  the  abscess  forms  at  the 
inner  angle  of  the  eye  it  is  termed  anchijlopsj  it  may  be 
mistaken  for  an  inflammation  of  the  lachrymal  sac,  but  the 
absence  of  a  previous  history  of  overflow  of  the  tears  wlU 
render  the  diagnosis  easy.  If  the  abscess  opens  through  the 
lid  margin  of  the  inner  canthus,  it  is  called  (jegilops. 

Teeatment. — If  the  case  is  seen  in  the  beginning,  the  use  of 
ice-cold  compresses  and  the  internal  administration  of  Aconite, 
Arsen.,  Apis,  Rhus  tox.,  or  Pulsatilla  according  to  the  follow- 
ing indications  will  enable  us  to  cause  resolution  without  the 
formation  of  pus. 

If  the  case  does  not  come  under  observation  or  the  remedies 
do  not  cause  a  subsidence  of  the  inflammation,  suppuration 
takes  place  and  hot  compresses,  or  poultices  of  ground  slippery 
elm  bark,  together  with  Hepar  sulph.,  Calc  hyp.,  and  Silicia 
will  be  required  to  hasten  the  formation  of  pus.  As  soon  as 
the  abscess  points,  or  fluctuation  can  be  determined,  the  con- 
fined pus  must  have  relief  by  a  free  incision  parallel  to  the  lid 
border,  made  with  a  sharp  pointed,  narrow,  curved  bistoury  or 
Beer's  cataract  knife.  Acute  blepharitis  is  likely  to  leave  some 
deformity  from  the  destruction  of  the  tissue  or  there  may  be  a 
general  hypertrophied  condition  of  the  lid,  and  a  predisposition 
to  attacks  of  swelling  and  styes. 

Aconite. — In  the  primary  stage  with  hard,  red,  swollen  con- 
dition of  the  lid,  great  heat  and  burning,  and  sensitiveness  to 
air  and  touch. 

Arsenicum. — Much  swelling  and  oedema  of  the  lids,  but 
with  less  redness  and  tension  than  under  Aconite.  The  pains 
are  burning  with  profuse,  hot  and  acrid  lachrymation,  and  the 
general  characteristics  of  Arsenicum  as  to  habit,  restlessness 
and  thirst. 

Ajyis  mel. — The  swelling  of  the  lids  is  usually  similar  to 
Arsenicum  but  more  red  and  often  reddish  blue.  The  pains 
are  stinging  and  cold  applications  give  relief.  There  may  be 
extensive  chemosis  of  the  conjunctiva  and  profuse,  hot  lach- 
rymation, but  usually  bland.  The  absence  of  thirst  and  the 
general  drowsy  condition  will  differentiate  it  from  Arsenicum. 


BLEPHARITIS  ACUTA— TREATMENT.  171 

Rhus  fox. — There  is  earrly  a  dusky  erythema  followed  by 
great  swelling  of  the  lids  with  more  or  less  oedema  and  ten- 
dency to  facial  erysipelas.  Chemosis  of  the  conjunctiva  is 
often  present.  The  pains  are  not  characteristic,  but  there  is 
relief  from  warm  applications  and  the  general  restlessness  and 
aggravation  at  night. 

Calc.  hypophos. — Often  of  benefit  in  ill-nourished  strumous, 
children  and  has  caused  resolution  without  suppuration.  The 
lid  symptoms  are  similar  to  those  of  Arsenicum.  After  sup- 
puration has  taken  place  the  destruction  of  tissue  is  much 
lessened  by  its  use. 

Hepar  sulph.  —  When  suppuration  is  impending  or  has 
already  begun.  The  lids  are  swollen,  hot,  with  throbbing 
aching  pains  and  extreme  sensitiveness  to  touch.  Hot  appli- 
cations are  soothing,  which,  if  allowed  to  become  cool,  increase, 
the  pains. 

Mercurius  sol.  —  Prevents  suppuration  in  some  cases  when 
indicated.  There  is  much  redness,  swelling  and  thickening 
of  the  lid,  with  great  sensitiveness  to  heat  or  cold  and  aggrava- 
tion at  night. 

Pulsatilla. — The  lids  are  swollen,  red,  and  thickened,  and 
the  acute  attack  frequently  follows  a  chronic  affection  of  the 
lid  margins  or  in  cases  where  recurrent  attacks  of  styes  have 
occurred.  The  pains  are  described  as  burning  and  itching, 
with  evening  aggravation  and  amelioration  from  cool  air. 

Silicia. — When  the  affection  arises  among  persons  working 
in  dark,  damp  or  cold  places  (Calc.)  It  is  more  useful  after 
suppuration  has  been  established,  hastens  repair  and  prevents 
extensive  loss  of  tissue.  The  pains  are  not  characteristic,  but 
there  is  a  sensitiveness  of  the  whole  head  and  relief  from, 
warmth;  aggravation  from  cold. 

Carbuncle  and  Malignant  Pustule  are  rarely  met  with  in 
the  eyelids;  they  present  the  same  features  as  when  occurring 
upon  the  other  portions  of  the  body  and  require  treatment  on. 
general  principles.  The  remedies  likely  to  be  required  are 
Ars.,  Lach.,  Rhus,  and  Silic.  The  diet  must  be  stimulating 
and  every  effort  made  to  sustain  the  patient's  strength.     The 


172  DISEASES  AND  INJURIES  OF  THE  EYE.' 

destruction  of  tissue  is  apt  to  be  Teiy  great  and  deformity  of 
the  lid  results. 

ERYSIPELAS  OF  THE  LIDS. 

Erysipelas  of  the  lids  is  usually  the  accompaniment  of  a 
similar  facial  affection,  but  the  lids  may  be  the  starting  point, 
and  erythema  or  hyperaemia  of  the  lids,  which  presents  a  bright 
scarlet  color  with  heat,  may  or  may  not  be  the  precursor  of 
erysipelas.  It  is  promptly  relieved  by  Bell,  internally.  Where 
erysipelas  attacks  the  lids  the  swelling  is  usually  soft,  with 
considerable  oedema  and  throbbing  pain.  Several  abscesses  may 
form  and  the  destruction  of  the  lids  be  consequently  great. 
Complications  destructive  to  vision  are  apt  to  occur  from 
extension  of  the  inflammation  to  the  orbital  tissue ;  sloughing 
of  the  cornea  may  result,  or  the  inflammation  extend  along  the 
optic  nerve  to  the  brain  causing  meningitis  and  optic  neuritis. 
Bell.,  Bhus,  Apis,  Ars.,  and  Verat.  virid.,  according  to  the 
indications  already  given,  with  a  generous  diet,  will  usually 
control  the  affection  and  prevent  disastrous  consequences. 

HORDEOLUM. 

Hordeolum  or  stye  (Plate  I,  Fig.  1)  is  a  furunculous 
inflammation  of  one  or  more  of  the  sebaceous  follicles  at  the 
roots  of  the  cilia ;  from  the  dense  character  of  the  connective 
tissue  of  the  outer  edge  of  the  lid  and  the  constant  motion  of 
the  parts,  the  swelling  which  follows  is  accompanied  by  an 
unusual  amount  of  pain.  The  swelling  and  oedema  may  be 
sufficient  to  close  the  lids  completely.  A  yellowish  point  soon 
appears  and  if  pricked  with  a  needle  or  opened  with  a  knife  a 
drop  or  two  of  pus  escapes  and  the  parts  rapidly  return  to 
their  normal  condition.  One  stye  is  apt  to  be  followed  by 
others  or  successive  groups  appear.  The  affection  occurs  in 
persons  suffering  from  some  gastric,  intestinal  or  uterine 
derangement,  and  is  frequently  associated  with  chronic  bleph- 
aritis or  conjunctivitis  due  to  refractive  troubles.  In  the 
inception   of  the  trouble   the  eyelash   which   appears  to  be 


PLATE  I 


, ,,  -'^ 


Hordeolum 


Chalazion 


Blepharoadenitis 


Ecbropium 


Symblepharon 


HORDEOLUM— CHALAZION.  173 

involved  sliould  be  extracted,  and  applications  of  ice  to  the 
inflamed  part,  together  with  the  internal  administration  of 
Pulsatilla  may  abort  it.  If  suppuration  has  commenced,  as  is 
usually  the  case  when  they  appear  for  treatment,  warm  poul- 
tices of  the  pulverized  slippery  elm  bark,  or  compresses  wet  in 
hot  chamomile  tea  will  hasten  the  pointing  of  the  abscess.  The 
general  health  of  the  patient  demands  attention,  to  prevent  the 
recurrence  of  the  trouble  and  the  removal  of  the  cause.  Calc. 
sulph..  Puis.,  Staph.,  Graph,,  Sulph.,  or  Thuya  as  indicated, 
administered  internally,  may  prevent  the  recurrence  of  the 
trouble. 

CHALAZION. 

A  chalazion,  or  meibomian  cyst  (Plate  I,  Fig.  2),  is  a  small 
tumor  of  the  lid  arising  from  the  distention  of  one  of  the 
follicles  of  the  meibomian  glands  imbedded  in  the  tarsus,  and 
is  usually  symptomatic  of  a  low  condition  of  the  system.  As 
it  increases  in  size  it  forms  a  little  hemispherical  swelling 
beneath  the  skin,  which  after  weeks  or  months  attains  the  size 
of  a  pea  or  bean.     The  skin  is  freely  movable  over  it  and  on 

everting  the  lids  the 
tissues  are  found  thin 
toward  the  conjunc- 
tiva and  present  a 
bluish  appearance. 
These  tumors  remain 

no.  66.  ,    .. 

stationary,  or  grow 
slowly,  and  then  become  inflamed  and  suppurate  at  times 
without  apparent  cause,  and  may  discharge  or  shrink  up. 
In  other  cases  the  tissue  becomes  so  thin  from  the  groA\-th 
of  the  tumor  that  the  conjunctiva  covering  it  ruptures,  and 
a  soft  pinkish  mass  extrudes,  causing  some  ii-ritation  as  it 
passes  over  the  eyeball.  Patients  apply  for  relief  from  the 
deformity  and  not  from  any  annoyance  from  the  enlarge- 
ment. Occasionally  the  internal  and  external  use  of  Thuya, 
Merc.  iod.  flav.,  or  Staph.,  may  cause  their  disappearance,  but 
the  most  rapid  method  of  treatment  is  by  a  crucial  incision 


174  DISEASES  AND  INJURIES  OF  THE  EYE. 

tlirougli  the  conjunctival  surface  over  the  growth,  on  tlie  ever- 
sion  of  the  lid,  never  through  the  skin,  and  the  contents  of  the 
cyst  which  are  cheesy,  gelatinous,  or  creamy,  removed  by  a 
scoop  made  for  the  purpose.  If  large,  portions  of  the  cyst 
wall  should  be  removed  by  the  forceps  and  a  minute  point  of 
nitrate  of  silver  introduced ;  care  should  be  exercised  to  prevent 
the  caustic  from  coming  in  contact  with  the  conjunctiva. 
Clamp  forceps,  as  in  Figs.  66  and  67,  to  inclose  the  tumor  and 
by  compression  of  the  lid  prevent  bleeding  which  becomes 
very  annoying,  have  been  devised  by  Desmarres,  Snellen, 
Xnapp  and  Prout  and  while  materially  assisting  the  operation 


FIG.  67. 

Bre  not  absolutely  necessary.  The  patient  should  be  directed 
to  apply  cold  applications  for  a  few  hours  after  the  operation 
if  there  is  any  painful  reaction  after  it.  The  deformity  does 
not  disappear  immediately,  as  the  cavity  left  after  the  removal 
of  the  tumor  fills  with  blood  which  is  not  absorbed  for  twenty- 
four  hours,  and  the  rough  edges  of  the  wound  may  cause  some 
discomfort  from  rubbing  against  the  cornea,  but  this  usually 
disappears  in  a  few  hours  if  the  eye  is  kept  quiet.  General 
tonic  measures,  together  with  the  correction  of  any  conjunc- 
tival trouble  and  the  avoidance  of  over  use  of  the  eyes  are 
indicated,  and  Staph.,  Thuya,  Calc.  iod.,  to  prevent  their 
recurrence  are  useful. 

BLEPHARO-ADENITIS. 

Blepharo-adenitis  (Plate  I,  Fig.  3),  blepharitis  marginalis, 
tinea  tarsi,  ophthalmia  tarsi  and  acne  ciliaris,  are  all  synony- 
mous terms  applied  to  the  chronic  inflammation  of  the  free 


BLEPHARO- ADENITIS.  175 

edge  of  the  lids,  leading  to  the  formation  of  small  pustules, 
superficial  ulcers  and  excoriations. 

Symptoms. — In  the  early  stages  of  the  disease  the  patient 
complains  of  weak  eyes,  that  they  are  glued  together  in  the 
morning,  and  that  there  is  much  itching  after  prolonged  use 
of  the  eyes;  the  edges  of  the  lids  look  red  and  raw.  The 
affection  usually  begins  with  the  appearance  of  a  few  hard 
crusts  at  different  portions  of  the  lid  edge  among  the  cilia, 
gluing  several  of  them  together.  These  are  difficult  to 
remove,  but  when  detached,  small  reddish  spots,  or  superficial 
ulcers  are  revealed.  Sometimes  the  lashes  have  small 
collections  of  pus  around  them.  As  the  disease  advances, 
the  inflammation  involves  all  the  follicles  of  the  cilia,  the 
edges  of  the  lids  become  much  thickened  and  rounded, 
and  the  puncta  closed,  giving  the  blear-eyed  expression  so 
characteristic  of  the  advanced  stages  of  this  ajffection.  A 
chronic  conjunctivitis  is  oftentimes  produced,  the  lashes  drop 
off,  and  the  new  ones  are  destroyed,  or  not  well  formed,  owing 
to  the  destruction  of  their  balbs,  and  the  lids  may  finally 
become  entirely  destitute  of  lashes,  presenting  the  condition 
kno^vai  as  madarosis  or  bald  lids.  If  not  checked  by  treat- 
ment the  cellular  tissue  of  the  lid  becomes  affected  and  con- 
tracting draws  the  free  edge  away  from  the  ball,  the  puncta 
become  everted,  and  the  tears  accumulating  cause  additional 
irritation. 

Causes. — It  is  a  frequent  accompaniment  of  diseases  of  the 
lachrymal  ducts,  and  arises  from  the  excoriation  due  to  the 
overflow  of  tears  and  requires  relief  of  the  obstruction  when 
it  exists  before  improvement  can  be  made  in  the  condition  of 
the  lid. 

The  disease  is  most  common  among  ill-nourished  children 
of  strumous  habit  Avitli  blonde  complexions,  and  is  frequently 
a  sequel  of  measles  or  scarlet  fever.  Conjunctivitis,  particu- 
larly of  a  granular  form,  as  well  as  refractive  errors  and 
muscular  weakness  are  a  frequent  accompaniment 

In  some  cases  the  presence  of  lice,  phthiriasis  ciliarum, 
in    the    eyelashes    may    be   mistaken    for    blepharitis    mar- 


1T6  DISEASES  AND  INJURIES  OF  TEE  EYE. 

ginalis  or  may  be  the  exciting  cause  of  the  inflammation. 
The  examination  witli  an  object-lens  will  show  signs  of  life  at 
the  root  of  the  lashes  and  nits  may  be  found  grafted  along 
the  stems  of  the  cilia.  The  larger  ones  can  be  picked  off 
with  a  pair  of  fine  forceps,  or  the  lids  may  be  bathed  in 
warm  water  and  Staphisagria  tincture  applied  along  the  roots 
of  the  lashes  with  a  camel's  hair  brush.  If  this  fails  a  small 
portion  of  blue  ointment  carefully  applied  to  the  lid  margins 
will  effect  a  cure. 

Treatment. — The  disease  is  often  exceedingly  obstinate  and 
may  last  for  years,  if  neglected.  AVhen  arising  from  refractive 
errors,  proper  glasses  must  be  prescribed  and  worn.  If  accom- 
panying a  chronic  conjunctivitis,  attention  must  be  directed  to 
its  relief,  as  it  is  almost  impossible  to  cure  the  glandular  inflam. 
mation  while  this  exists.  If  the  punctum  is  everted,  it  is  well 
to  slit  the  canaliculus,  and  if  there  is  much  thickening  of  the 
conjunctiva  a  mild  collyrium  of  borax  gr.  viii  to  f3J  is  of  fre- 
quent service-  General  treatment  is  necessary  in  the  majority 
of  cases,  the  diet  should  be  nutritious,  the  patient  Avarmly 
clothed,  and  above  all  cleanliness  insisted  upon.  The  crusts 
must  be  removed  every  morning  by  the  patient  or  attendants, 
after  softening  them  in  warm  water.  This  is  more  readily 
done  after  the  application  of  glycerine  or  some  oily  substance 
to  the  lids  the  night  before.  During  the  day  the  accumulation 
on  the  lashes  should  be  removed  as  soon  as  formed,  and  if  the 
crusts  are  hard,  they  should  be  softened  by  bathing  with  a 
warm  alkaline  solution  of  sodre  bicarb,  gr.  xx  to  3J;  borax 
solution  gr.  x  to  3J ;  or  tar  water,  for  ten  or  fifteen  minutes  and 
then  thoroughly  removed;  after  they  are  removed,  some  mild 
vaseline  ointment  may  be  rubbed  among  the  roots  of  the  lashes, 
when  the  lids  are  closed.  This  will  materially  relieve  the 
irritation  arising  from  the  formation  of  the  crusts  and  at  the 
same  time  hasten  the  cure.  The  ointments  most  commonly 
in  use  for  this  purpose  are  grapho-cosmoline,  yellow  oxide  of 
mercury,  the  white  precipitate,  or  the  red  oxide,  gr.  ii  ad  3ij 
of  vaseline.  Where  there  is  a  tendency  to  recurrence 
pulling  out  the  eyelashes  as  they  loosen  often  proves  of  bene- 


BLEPHARO-ADENITIS— TREATMENT.  177 

fit;  where  the  entire  lids  are  involved,  and  red  and  painful, 
slippery  elm  poultices  at  night  afford  much  relief. 

If  the  disease  has  advanced  to  that  stage  where  the  eye- 
lashes have  been  destroyed  and  the  lid  margins  rounded  off 
and  reddened,  relief  from  the  exciting  cause,  and  proper  medi- 
cation will  lessen  the  deformity,  but  will  not  re-produce  the 
cilia. 

Aconite. — Indicated  in  an  acute  attack,  but  such  cases  are 
extremely  rare,  and  when  occurring,  result  from  exposure  of 
the  eyes  to  dry  cold  winds  during  long  drives.  The  lid  mar- 
gins are  swollen,  hot  and  dry,  and  there  is  more  or  less  inflam- 
mation of  the  conjunctiva  accompanying  it. 

Graphites. — The  action  upon  the  edges  of  the  lid  is  very 
marked,  and  is  perhaps  the  most  useful  remedy  we  possess  for 
the  chronic  form  of  blepharitis,  particularly  when  occurring 
in  strumous  subjects  and  accompanied  by  the  moist,  fissured 
and  easily  bleeding,  eczematous  eruptions  on  the  cheeks  or 
behind  the  ears,  which  are  so  promptly  cured  by  this  remedy. 
The  swelling  of  the  margins  of  the  lids  is  variable,  in 
color  pale  red,  and  crusted  with  dry  scabs  which  cover 
spots  of  ulceration,  or  numerous  fine  scales  are  found  on  the 
skin  and  among  the  cilia  which  can  be  brushed  off.  There  is 
much  itching,  burning  and  biting  of  the  lids  which  the  patient 
tries  to  relieve  by  rubbing,  but  this  only  aggravates  the  trouble. 
In  many  cases  there  is  a  fissured  condition  of  the  skin  of  the 
outer  canthus,  which  bleeds  readily  from  rubbing  or  opening 
the  eyelids.  The  cure  is  hastened  by  the  application  of  the 
graphites  ointment  to  the  lids  at  night. 

Mercurius. — The  various  forms  of  mercury  are  extremely 
useful  in  blepharitis,  the  Merc.  sol.  or  vivus  more  frequently 
perhaps  than  the  others.  The  lids  are  much  thickened,  red, 
and  often  ulcerated,  with  sensitiveness  to  touch,  heat  and  cold. 
The  lid  conjunctiva  is  hypersemic,  or  inflamed,  with  an  acrid 
lachrymation  which  increases  the  irritation  of  the  lids.  There 
is  an  aggravation  of  the  whole  condition  from  exposure  to  the 
light  and  heat  of  fii-es,  or  in  the  evening  from  artificial  light. 
Tlie  local  application  of  an  ointment  containing  grs.  ii  of  the 

12 


178  DISEASES  AND  INJURIES  OF  THE  EYE. 

mere,  precip.  alb,  or  the  mere.  iod.  flav.  to  5ij  of  vaseline  will 
be  found  very  useful. 

Merc.  cor.  and  prot.  present  similar  symptoms,  but  in  a 
more  marked  degree  and  where  there  is  a  pustular  eruption  on 
the  parts  about  the  eye  or  upon  the  conjunctiva. 

The  prescription  must  be  based  upon  a  careful  consideration 
of  the  circumstances  and  symptoms  as  well. 

Sulphur. — Suitable  in  a  large  number  of  cases  occurring  in 
scrofulous  children  where  the  disease  is  occasioned  by  the 
debility  following  the  exanthematous  diseases,  or  appears  as 
the  accompaniment  of  eczema  of  the  face  or  head  for  which 
Sulphur  would  be  indicated.  The  lids  are  red,  swollen,  with 
numerous  small  points  of  suppuration,  or  are  ulcerated  along 
the  edges.  The  characteristic  pains  are  fine,  sharp  and  stick- 
ing, though  itching,  biting,  burning  and  many  other  sensations 
may  be  present.  There  is  usually  an  aggravation  from  wet 
applications  to  the  parts  as  well  as  a  general  aversion  to  being 
washed. 

Pulsatilla.— In  cases  arising  from  some  gastric  derangement 
dependent  upon  high  living  with  consumption  of  fat  foods. 
There  is  a  great  tendency  to  the  formation  of  styes,  and  fre- 
quently acne  of  the  face.  The  swelling  and  redness  of  the 
lids  may  vary,  though  there  is  usually  a  rather  profuse,  bland 
discharge  which  agglutinates  the  lids  during  the  night. 
Itching  and  burning  are  complained  of,  with  a  general  evening 
aggravation  and  from  a  close  or  warm  atmosphere,  with  relief 
from  fresh  cool  air. 

Arsenicum. — Blepharitis  occurring  in  cases  where  the  gen- 
eral condition  presents  the  debility,  restlessness,  thirst,  night 
aggravation,  etc.,  of  Ars.  The  lids  are  often  puffed  and  their 
edges  very  red,  and  excoriated  by  the  acrid  lachrymation 
which  is  a  frequent  accompaniment  of  the  condition — again 
the  lids  may  be  smooth,  red,  and  shed  numerous  scales.  The 
pains  are  burning  in  character. 

Calc.  carb. — Especially  adapted  to  blepharitis  in  fat, 
unhealthy  children  who  sweat  much  about  the  head.  The 
lids  are  swollen,  oedematous  and  red,  with  a  thick,  excoriating. 


•  BLEPHARO-ADENITIS— TREATMENT.  179 

purulent  discharge,  accompanied  by  great  itching  and  burning 
of  the  lid  margins,  particularly  at  the  canthi,  with  aggravation 
from  damp  weather  and  in  the  morning. 

Calc.  jylios.  and  iod.  are  serviceable  in  strumous  cases  pre- 
senting enlargement  of  the  tonsils  and  cervical  glands,  with 
the  eye  symptoms  of  the  carhonaie. 

Hepar  sidph. — The  lid  margins  are  studded  with  small 
ulcers  Avhich  destroy  the  lid  tissue ;  or  they  are  thick,  inflamed 
and  tender  to  the  touch,  with  small  furunculous  swellings  along 
the  margins  or  in  the  meibomian  glands;  eczematous  condi- 
tion of  the  face  or  outer  canthus  of  the  lid  with  cracking  and 
bleeding  on  opening  the  eyes  (see  Graph.). 

Peiroleiim. — Indicated  in  afi"ection8  of  the  lid  when  there  is 
itching  and  dryness,  with  smarting  and  sticking  pains  in  inner 
canthus.  The  skin  of  the  lid  is  often  rough  and  dry,  and 
frequently  accompanied  by  the  occipital  headache  character- 
istic of  Petroleum.  The  external  application  of  vaseline  or 
cosmoline  softens  the  skin  and  prevents  the  rapid  formation  of 
the  crusts  and  the  gluing  together  of  the  lids,  and  thus  by 
giving  relief  from  this  annoyance  exerts  a  beneficial  influence. 

Nux  vom. — Cases  occurring  in  adults  where  there  is  much 
smarting  and  burning  with  aggravation  in  the  evening,  and 
when  complicated  with  gastric  derangement  which  is  often  due 
to  constant  indulgence  in  stimulants. 

Antim.  crud. — Curative  in  cases  occurring  in  children  where 
Graphites  seems  indicated,  but  when  administered  gives  no 
result.  The  lids  are  inflamed,  swollen,  moist,  and  there  is  a 
pustulous  eruption  upon  the  lids  or  upon  the  face,  with  fre- 
quent agglutination  and  photophobia  in  the  morning. 

Natrum  mur. — Useful  where  the  lids  are  inflamed  and 
thickened,  accompanied  by  smarting  and  burning,  with  some 
conjunctival  inflammation  and  a  sensation  of  sand  in  the  eyes. 
The  lachrymation  is  acrid  and  excoriates  the  lids  and  cheek, 
giving  them  the  characteristic  glossy  appearance. 

JRhus  tox. — Suitable  in  some  cases  where  there  is  heaviness 
and  stiflEness  of  the  lids,  or  an  cedematous  condition  with 
profuse  lachrymation. 


180  DISEASES  AND  INJURIES  OF  THE  EYE. 

Sepia. — Scaly  conditions  of  the  lids,  or  small  points  of 
pustular  inflammation  at  the  roots  of  the  cilia,  with  a  sensation 
as  if  the  lids  pressed  too  hard  on  the  eyeball. 

Staphisagria. — Lids  with  dry,  uneven  margins  or  hard 
nodules,  and  much  itching  and  sensation  of  dryness  of  the 
eyes  in  the  morning. 

Argentum  nit,  Euphras.,  Antim.  tart,  and  Merc.  nit.  may  be 
indicated  in  cases  dependent  upon,  or  associated  with,  conjunc- 
tival disease;  other  medicines  may  relieve  when  indicated  by 
the  general  symptoms  of  the  remedy  without  special  reference 
to  the  eye  symptoms. 

TRICHIASIS. 

Trichiasis  or  inversion  of  one  or  more  of  the  eyelashes,^ 
is  a  frequent  result  of  chronic  and  neglected  iniiammatiou  of 
the  conjunctiva  and  lid  margins.  The  incurved  cilia,  if 
allowed  to  remain,  give  rise  to  a  persistent  conjunctivitis, 
haziness  or  vascularity  of  the  cornea. 

The  separation  of  the  double  row  of  lashes,  with  the  inver- 
sion of  one  of  them,  disiichiasis,  occurs  occasionally  as  a 
congenital  condition,  and  the  inner  row  under  these  circum- 
stances is  inverted  and  is  constantly  rubbing  the  cornea  and 
conjunctiva. 

Treatment. — The  treatment  is  purely  surgical  and  depends 
upon  the  extent  of  the  disease.  If  only  a  few  of  the  cilia  are 
directed  against  the  eyeball  they  should  be  seized,  one  by  one, 
by  a  pair  of  cilia  forceps  (Fig.  68),  and  extracted.  To  do 
this  properly  and  carefully,  and  with  the  least  pain  to  the 
patient,  requires  skillful  manipulation.  To  extract  the  cilia 
properly,  the  patient  should  be  seated,  and,  the  surgeon  stand- 
ing behind,  gentle  pressure  upon  the  lid  with  the  thumb  or 
finger  is  made  while  a  pair  of  forceps  with  broad  ends  and 
smooth  surfaces,  which  meet  perfectly  for  at  least  an  eighth 
of  an  inch,  are  used.  The  forceps  are  passed  over  the  lash 
to  the  skin,  compressed,  and  the  lash  extracted  by  a  firm  but 
quick  pull.  If  the  lash  is  not  seized  near  the  root,  it  is  apt 
to  be  broken  off.     If   the   lashes    are    light  in  color  and  ill 


TRICHIASIS.  181 

formed,  difficulty  is  often  experienced  in  determining  their 
position,  but  if  the  patient  is  directed  to  rotate  the  eyeball  in 
such  a  manner  as  to  bring  the  pupil  behind  the  lash  a  dark 
background  is  formed  on  which  the  offending  object  is  easily 
distinguished  and  may  be  seized  with  the  forceps  and  extracted. 
The  lashes  thus  removed  will  grow  again,  but  the  removal  of 
the  associated  disease,  whether  it  be  a  conjunctivitis  or  lid 
affection,  with   the   constant  epilation,  will   finally  result,  in 

many  cases,   in 

-^^ ^    their   destruc- 

^''''^-  ^  tion.       If    only 

^-^^-^-==.,,,,,^^^^^^1111^^  one     or     two 

^^^^^'''■^''^^^^^SE^^         lashes   turn  in, 

FIG.  68.  .  T 

their  direction 
may  often  be  improved  by  a  little  operation  revived  by  Snel- 
len, called  reposito  ciliarum.  Both  ends  of  a  fine  silk  thread 
are  brought  through  the  eye  of  a  delicate  needle  which  is 
carried  through  the  free  edge  of  the  lid  just  outside  of  the 
root  of  the  misplaced  eyelash  and  brought  out  on  the  skin 
at  1  or  2  mm,  from  the  border.  The  looped  end  of  the  thread 
is  carefully  placed  around  the  cilia,  which  is  then  dragged 
through  the  puncture  made  by  the  needle.  It  is  by  no  means 
permanently  successful,  but  is  frequently  performed,  and 
occasions  no  deformity.  Knapp  suggests  that  the  lash  itself 
be  threaded  in  the  eye  of  the  needle  and  drawn  into  position. 
A  plan  has  been  recommended  to  get  rid  of  a  group  of 
several  lashes  by  means  of  a  silk  ligature  introduced  so  as  to 
include  them  and  then  tightly  tied.  Much  pain  and  inflamma- 
tion follow  the  operation  and  the  result  is  unsatisfactory  when 
the  whole  or  a  portion  of  the  lashes  are  involved.  The  radical 
cure  of  the  trouble  consistc  in  the  cutting  out  of  the  follicles 
of  the  lashes  at  the  border  of  the  lid  or  transplanting  the 
ciliary  portion  further  up  on  the  lid.  It  may  be  effected  in 
the  following  manner:  A  horn  spatula,  made  for  the  purpose 
(Fig.  69),  is  passed  under  the  lid  to  render  it  tense  and  to 
protect  the  eyeball.  The  lid  is  split  by  an  incision  made 
about  one-fourth  of  an  inch  deep  along  the  edge  of  the  lid 


182 


DISEASES  AND  INJURIES  OF  THE^  EYE. 


parallel  to  and  within  the  roots  of  the  cilia.  A  second  incis- 
ion is  next  made  through  the  skin  in  a  plane  at  right  angles 
to  the  former  along  the  whole  length  of  the  lid,  or  that  por- 
tion where  the  distorted  cilia  are  imbedded,  so  that  a  strip  of 
skin  is  removed  containing  the  roots  of  the  lashes.     The  re- 


action is  slight  and  requires  only  a  cold  water  dressing. 
"When  only  a  small  portion  of  the  eyelashes  are  at  fault  they 
may  be  extracted,  and  the  endeavor  made  to  destroy  the  bulbs 
by  the  introduction  of  hot  needles  into  the  follicles  while  the 
lid  is  held  in  a  clamp.  Transplantation  of  the  outer  portion 
of  the  lid  containing  the  ciliary  row  may  be  useful.    (Fig.  70). 

The  operation  is  made  in  the  following 
manner:  the  patient  is  etherized  and 
the  lid  held  tense  on  a  horn  spatula 
beneath,  so  as  to  protect  the  eyeball, 
when  a  thin  narrow  scalpel  is  intro- 
duced into  the  border  of  the  lid  in  a 
line  between  the  mouths  of  the  mei- 
bomian ducts  and  the  lashes,  and  the 
lid  split  throughout  its  entire  length 
to  the  depth  of  one-fourth  or  one- 
third  of  an  inch,  so  that  the  portion 
containing  the  cilia  is  movable  upon 
the  surface  from  which  it  has  been 
separated.  An  elliptical  strip  of  skin  one-fourth  to  one-half 
an  inch  wide  with  the  underlying  muscular  fibre  is  now  dis- 
sected out  of  the  middle  of  the  lid,  and  the  edges  brought 
together  with  sutures ;  the  part  at  the  border  of  the  lid  exposed 
by  the  transplantation  of  the  ciliary  portion  is  left  to  heal  by 
granulation.     If  the  tissues  are  not  carefully  handled,  or  the 


FIG.  70. 


ENTROPIUM—TREA  TMENT. 


183 


dissection  made  too  freely,  there  is  danger  of  sloughing, 
which,  while  it  may  relieve  the  trichiasis,  does  not  improve 
the  appearance  of  the  patient.  A  light  bandage  should  be 
applied  after  the  operation  and  if  there  is  but  slight  reaction, 
the  parts  heal  by  first  intention  and  the  sutures  are  removed 
after  forty-eight  to  seventy-two  houi's. 

ENTROPIUM. 


riG.  71. 


Inversion  of  the  margins  of  the  eyelids  against  the  eyeball 
may  be  partial  or  complete.      (Fig.  71),     A  partial  entropium 

with  trichiasis  may  be  due  to 
permanent  contraction  of  the 
fibres  of  the  orbicularis  which 
lie  close  to  the  free  border  of 
the  lid,  a  result  which  follows 
in  long-continued  cases  of 
photophobia. 

Spasmodic  Enteopium. — A 
form  of  entropium  (Fig.  72) 
due  to  spasm  of  the  orbicularis,  termed  senile  entropium, 
occurs  in  old  people  with  lax  and  wrinkled  skin,  and  is  some- 
times seen  after  bandaging  the  eyes  after  cataract  operation. 
The  lower  lid  is  generally  affected 
and  the  ciliary  margin  is  rolled  in 
upon  itself  so  as  to  be  invisible 
unless  the  skin  of  the  lid  is  re- 
tracted, when  it  assumes  its  normal 
position  to  return  soon  after  the 
traction  is  relieved;  the  fibres  of 
the  orbicularis,  near  the  edge  of 
the  lid,  contract  and  turn  the  cilia 
inward  again,  and  thus  the  cornea  and  conjunctiva  become 
irritated  from  the  constant  rubbing  of  the  lashes,  and  serious 
changes  occur. 

Treatment — If  the  condition  has  arisen  from    bandaging, 
the  removal  of   the  cause  and    the  application    of   collodion 


184  DISEASES  AND  INJURIES  OF  THE  EYE. 

painted  on  the  lid,  or  strips  of  plaster,  may  retain  it  for  a 
sufficient  length  of  time  in  its  normal  position  to  allow  the 
fibres  of  the  orbicularis  to  recover  from  the  spasmodic  condi- 
tion. In  other  cases  much  benefit  is  derived  from  the 
patient's  constant  attention  to  the  lid  at  frequent  intervals  of 
the  day.  He  should  be  directed  to  draw  upon  the  skin  of  the 
lids  sufficiently  to  bring  the  cilia  into  proper  position  as  often 
as  possible.  In  other  cases  the  excision  of  an  elliptical  por- 
tion of  the  skin  of  the  lid  may  be  sufficient  to  relieve  the  con- 
dition. 

Causes. — Entropium  is  commonly  caused  from  the  contrac- 
tion of  the  conjunctiva  after  trachoma  or  granular  conjunctiv- 
itis. The  cicatrices  formed  in  the  conjunctival  tissue  as  the 
effect  of  the  trachoma,  contract  and  increase  the  curvature  of 
the  tarsus  to  such  an  extent  that  the  ciliary  margin  of  the 
affected  lid  is  turned  inward.  Together  with  this  condition, 
the  lashes  are  irregular  and  distorted,  and  constantly  rubbing 
against  the  cornea  they  destroy  its  transparency  and  occasion 
much  irritation.  In  these  cases  the  lids  present  so  much 
structural  change  that  it  is  impossible  to  restore  the  cilia  to 
their  normal  position  by  the  retraction  of  the  skin  of  the  lid. 

Treatment. — The  treatment  consists  either  in  removing  tlie 
cilia  together  with  their  bulbs,  so  as  to  roliove  the  irritation  of 
the  cornea,  or  the  performance  of  an  operation  for  the  relief  of 
the  entropium.  Hotz'  s  operation  for  trichiasis  and  entropium 
is  an  admirable  one  for  the  cure  of  many  of  these  cases,  and 
consists  essentially  of  a  transverse  incision  of  tin  lid  along 
the  upper  or  lower  border  of  tho  tarsus  according  as  the  oper- 
ation is  made  upon  the  superior  or  inferior  lid,  the  excision  of 
a  portion  of  the  muscular  layer  3  to  4  mm.  in  width  and  the 
insertion  of  deep  sutures  through  the  tarsal  border  and  the 
tarso-orbital  fascia.  The  operation  is  performed  in  the  follow- 
ing manner:  the  skin  of  the  brow  is  fixed  by  the  pressure  of 
the  finger  of  an  assistant  at  that  point.  The  ciliary  margin  of 
the  lid  is  seized  at  the  centre  between  the  thumb  and  fore- 
finger, or  with  a  pair  of  forceps  if  the  cilia  are  short,  and 
drawn  downward  so  that  the  cui-ved  furrow  in  the  skin  of  the 


ENTROPIUM—CANTHOPLASTY. 


185 


FIG.  73. 


lid,  wliicli  beoriiis  about  2  mm.  above  the  inner  cantlius  and 
marks  the  upper  border  of  the  tarsus,  becomes  a  straight  hori- 
zontal line.  A  transverse  incision  is  now  made  through  the 
integument  and  muscles  to  the  aponeu- 
rosis of  the  tarsus,  care  being  exercised 
to  prevent  an  incision  of  the  tarso- 
orbital  fascia.  A  strip  of  the  muscular 
layer  of  the  orbicularis  from  3  to  4 
mm.  in  width  and  the  length  of  the 
wound  is  excised,  the  dissection  being 
thoroughly  done,  so  as  to  leave  no 
muscular  fibres  on  the  upper  border  of 
the  tarsus.  After  all  hemorrhage  has  ceased,  the  sutures  are 
to  be  introduced  in  the  manner  shown  in  Fig.  73,  being  passed 
throuf^h  the  integument  of  the  lower  edo^e  of  the  wound  as  at 
/  in  Fig.  74  and  thence  through  the  aponeu- 
rosis a  h  and  brought  out  and  passed  through 
the  integument  at  d.  After  seeing  that  no 
muscular  fibres  are  included  between  the 
sutures,  they  are  tightened.  Four  or  five 
sutures  are  required  and  the  success  of  the 
operation  is  dependent  upon  the  insertion  of 
the  sutures  into  the  true  upper  border  of  the 
tarsus.     If  the  tarsus    is    thickened  and  con-  tig.  74. 

tracted,  Streatfield's  operation  for  grooving  the  cartilage  is 
advantageously  combined  with  the  operation.  After  the 
operation  is  completed,  cold  compresses  are  applied  and  the 
stitches  removed  on  the  third  or  fourth  day. 


CANTHOPLASTY. 


Entropium  is  frequently  associated  with  or  caused  by 
shrinking  of  the  tarsus  from  side  to  side,  and  the  palpebral 
fissure  becomes  shortened  In  other  cases  the  pressure  of  the 
thickened  lid  upon  the  eyeball  is  such  as  to  injure  its  integrity. 
For  the  enlargement  of  the  palpebral  fissure  the  operations  of 
canthotomy  or  canthoplasty  are  made.     The  former  is  intended 


186 


DISEASES  AND  INJURIES  OF  THE  EYE. 


simply  for  temporary  relief  and  is  accomplished  by  dividing 
the  outer  canthus  horizontally  in  the  line  of  the  raphe  with  a 
pair  of  scissors  or  with  a  scalpel.  The  canthoplastic  operation 
(Fig.  75)  is  rather  more  extensive.  A  curved  bistoury  is 
introduced  into  the  conjunctival  sac  at  the 
outer  canthus,  pushed  horizontally  outward  to 
the  edge  of  the  orbit  in  a  line  with  the  com- 
missure of  the  lids,  and  made  to  cut  its  way 
l|  out  through  the  conjunctiva,  skin  and  inter- 
vening tissues.  The  skin  and  conjunctiva  are 
then  united  by  three  sutures,  one  at  the  outer 
angle,  and  the  other  two  midway  on  each  lip 
Fia.  75.  of  the  wound. 

When  the  conjunctiva  is  much  atrophied  and  the  palpebral 
fissure  much  contracted  a  still  more  extensive  operation  is 
demanded.  That  devised  by  Noyes  will  be  beneficial;  this 
consists  in  the  formation  of  a  flap  from  the  skin  of  the  temple, 
which  is  turned  down  and  placed  in  the  external  canthus,  and 
secured  with  sutures. 


ECTROPIUM. 


Ectropium  or  eversion  of  the  lids  (Plate  I,  Fig.  4)  (Fig.  76), 
is  more  serious  than  entropium,  as  the  conjunctiva  is  exposed 
and  becomes  thickened  with  exuberant  granulations  or  dries 
up.  The  tears  run  over,  and  the 
eyeball  being  exposed  to  irritation 
soon  suffers.  The  eversion  may 
take  place  in  either  lid,  though  the 
lower  is  more  generally  affected. 

Causes. — The  causes  which  occa- 
sion it  are  chronic  thickening  of 
the  conjunctiva  following  purulent 
or  granular  inflammations,  blephar- 
itis marginalis,  paralysis  of  the  seventh  nerve,  contraction  of 
the  skin  from  burns,  wounds,  cancerous  growths,  or  caries  of 
the  bones  of  the  orbital  margin. 


ECTROPIUM—TREA  TMENT. 


187 


Treatment. — Operations  for  the  relief  of  ectropium  are 
numerous  and  individual  cases  require  modifications  of  them, 
or  additional  operations  to  suit  the  peculiar  existing  conditions. 
Wharton  Jones'  operation  (Fig.  77)  an- 
swers very  well  in  cases  where  the 
deformity  is  not  very  great.  It  may  bo 
made  upon  either  the  upper  or  lower  lid, 
but  suits  the  latter  best.  For  the  opera- 
tion a  horn  spatula  is  introduced  into 
the  conjunctival  sac, 
and  a  triangular  flap 
is  made  with  the 
base  towards  the  ciliary  margin,  suffi- 
ciently great  to  allow  the  lid  to  return  to 
its  place.  The  flap  is  then  dissected  up, 
care  being  taken  not  to  go  too  deep  or 
involve  the  conjunctiva.     The  lines  of  the 

incision  are  then  brought  together 
with  sutures  as  in  Fig.  78.  When 
it  is  necessary  to  shorten  the  lid, 
it  may  be  combined  with  tarso- 
raphy.  When  it  is  desirable  to 
shorten  the  lid  without  tarsoraphy 
the  operation  of  Adams,  see  Figs. 
79-80,  may  be  employed.  As 
there  is  no  elevation  of  the  lid 
from  the  operation,  it  should  be 
performed  at  the  outer  cantlius. 
Here  a  Y-shaped  incision  is  made 
through  the  conjunctiva  and  thick- 
ness of  the  lid,  the  included  portion 
removed,  and  the  edges  of  the  wound 
accurately  approximated  with  sutures 
as  in  Fig.  80.  In  severe  cases,  Dif- 
fenbach's  operation  which  also  short- 
ens the  lid  may  be  found  expedient, 
particularly  when  the  ectropium  is 


188 


DISEASES  AND  INJURIES  OF  THE  EYE. 


FIG.  81. 


•dependent  upon  a  contracting  cicatrix.  The  latter  is  first 
dissected  away,  as  in  Fig.  81,  so  as  to  leave  a  triangular 
wound  witli  the  base  towards  the  lid  margin  and  the  tarsus 
preserved  if  possible.  If  not,  the  con- 
junctiva is  carefully  dissected  off  and 
laid  upon  the  eyeball  while  a  rectan- 
gular incision  (Fig.  82)  is  made 
through  the  sound  skin  at  the  outer  or 
inner  canthus  as  deemed  best;  the 
inclosed  flap  is  then  dissected  from  the 
subcutaneous  tissue  and  slid  into  posi- 
tion and  secured  by  fine  sutures.  The 
flap  should  be  larger  than  that  appar- 
ently needed  to 
fill  the  gap, 
^vhile  the  surface  left  by  the  trans- 
planted flap  is  to  be  filled  with  small 
skin  grafts.  A  water  compress,  or  a 
light  retaining  bandage  is  to  be  applied, 
or  if  sloughing  of  a  portion  of  the  flap 
takes  place  the  temperature  of  the  part 
must  be  improved  by  frequent  applica- 
tions of  warm  water. 

Yon  Graefe's  operation  is  indicated  ±itr.  h^. 

in  cases  of   elongation  of  the   lid  resulting   from    blepharo- 
adenitis,  but  space  does  not  admit  of  further  description. 

TARSORAPHY. 

As  canthoplasty  was  advocated 
in  entropium,  the  converse  opera- 
tion should  be  performed  in 
ectropium.  In  the  performance 
of  this  operation,  the  edges  of  the 
lid,  as  far  as  may  be  considered 
necessary,  are  freshened  by  re- 
moving the  skin  from  the  cilia  to 


the   inner  edge,   as  in 


Fig. 


83, 


BLEPHAROPLASTY. 


189 


sparing  as  much  as  possible  the  openings  of  the  meibomian 
glands,  and  freshening  the  commissural  folds.     Two  to  four  fine 

silver  sutures,  as  in  Fig,  81^ 
are  passed  through  the  whole 
border  of  the  lids,  the  fresh- 
ened parts  are  brought  accu- 
rately together  and  a  pressure 
bandage  insures  union.  This, 
operation  may  also  be  used 
when  the  palpebral  fissure  ia 
^Q.'g*.  too  large  from  any  cause. 


BLEPHAROPLASTY. 


If,  as  a  consequence  of  wounds,  ulcerations,  or  cancerous 
growths,  the  eyelids  have  become  more  or  less  destroyed,  they 
may  be  restored  in  many  cases  by  plastic  operations.  For 
this  purpose  the  operation  of  Diffenbach  may  be  used.  Whea 
only  part  of  the  lid  has  been  removed,  a  similar  operation 
proposed  by  Arlt  is  useful.  After  removing  the  portion  a,  6, 
c,  Fig.  85,  by  a  slightly  curved 
incision  the  flap  e,  cZ,  /,  is  made. 
The  angle  c,  is  united  to  the 
angle  a.  The  internal  palpe- 
bral ligament  affords  sufficient 
support  to  prevent  the  sliding 
of  the  flap  downward  which  is 
maintained  by  horizontal  su- 
tures. The  end  d,  of  the  flap 
is  united  by  one  or  two  sutures 
to  cj  the  edge  of  the  flap  d,  /, 
forms  the  inner  border  of  a 
triangular  space  left  by  the 
sliding  of  the  flap  which  is  to  be  filled  by  grafting. 

Knapp's  operation  (Fig.  8G)  gives  satisfactory  results  where 
a  portion  of  the  lid  has  been  destroyed  by  epithelioma  or  can- 
cerous growths.     After  complete  dissection  of  the  growth,  the 


190 


DISEASES  AND  INJURIES  OF  THE  EYE. 


incisions  are  made  as  indicated  in  the  cut,  and  the  flaps 
loosened  and  stretched  to  cover  the  wound  and  united  by 
sutures.      The   operation   of  tarsoraphy  combined  with  skin 


grafting  may  enable  us  to  dispense,  in  some  cases,  with  an 
operation  for  blepharoplasty. 

PTOSIS. 

Drooping  of  the  upper  lid  may  be  complete  or  incomplete, 
and  is  due  to  paralysis  of  the  third  nerve,  to  deficient  power 
of  the  levator,  or  to  increased  weight  of  the  lid  from  hyper- 
trophy of  its  tissues.  The  power  of  the  levator  is  in  direct 
ratio  to  the  normal  weight  of  the  lid,  and  those  conditions 
which  increase  its  weight,  as  blepharitis,  granular  conjuncti- 
vitis, oedema,  erysipelas,  abscess,  tumors,  deposits  of  fat,  or 
prolonged  bandaging,  disturb  the  natural  balance,  and  the 
levator  is  no  longer  able  to  raise  the  lid  as  before.  It  is 
necessary  to  distinguish  between  the  condition  arising  from 
paralysis  and  that  from  a  thickening  of  the  lid.  This  may 
be  readily  accomplished  by  pinching  up  a  fold  of  the  lid 
between  the  thumb  and  finger,  when,  relieved  of  the  extra 
weight,  the  levator  will  act  if  the  ptosis  is  due  to  the  latter 
condition.  If  the  lid,  under  these  conditions,  remains  immov- 
able the  trouble  is  due  to  paralysis.  "When  the  ptosis  arises 
from  an  affection  of  the  third  nerve,  the  other  muscles 
supplied  by  the  nerve  will  generally  participate,  and  when 
the  lid  is  raised  the  eyeball  will  be  turned  outward  and 
diplopia  be  produced.  When  the  levator  only  is  deficient,  the 
defect  may  be  congenital;  reflex,    from   injury  of   the  fifth 


PARALYSIS  OF  THE  ORBICULARIS.  191 

nerve;  or  the  result  of  injury,  and  on  raising  the  lid  the  eye- 
ball and  vision  appear  normal. 

Treatment. — The  cause  must  be  determined  and  removed. 
If  due  to  diseased  conditions  of  the  lid  these  must  be  relieved 
by  appropriate  treatment,  when  the  ptosis  will  disappear.  The 
temporary  loss  of  power  following  oedema,  or  inflammation  of 
the  lids,  is  recovered  as  the  parts  regain  their  normal  state,  and 
hence  requires  no  special  treatment.  When  dependent  upon 
paretic  or  paralytic  affections  of  the  levator,  the  internal  use 
of  such  remedies  as  Causi,  Gels.,  Rhus,  or  Spig.,  together 
with  the  faradic  or  interrupted  galvanic  current,  will  prove 
useful  in  many  cases. 

No  operation  for  the  relief  of  the  ptosis  should  be  under- 
taken until  three  or  four  months  have  elapsed,  and  other 
treatment  has  proved  unavailing.  If  paralysis  of  the  internal 
rectus  is  associated  with  the  ptosis  and  no  relief  has  been 
gained  from  remedial  treatment,  it  is  not  expedient  to  make  an 
operation  for  the  relief  of  the  drooping  lid,  as  the  retraction 
of  the  lid  would  increase  the  patient's  discomfort  by  causing 
the  diplopia  to  become  permanent. 

PARALYSIS  OF  THE  ORBICULARIS. 

Loss  of  power  of  the  orbicularis  may  be  due  to  lesion  of  the 
seventh  nerve  and  is  one  of  the  symptoms  of  facial  paralysis. 
The  eye  cannot  be  closed  by  the  action  of  the  orbicularis  and 
remains  open,  producing  the  condition  termed  LagopMhalmos. 
This  condition  may  also  arise  from  atrophy  of  the  muscular 
fibres  of  the  orbicularis.  There  is  more  or  less  drooping  of 
the  lower  lid,  and  overflow  of  tears  from  the  eversion  of  the 
punctum,  and  when  the  condition  is  only  a  paresis,  the  over- 
flow of  tears  may  be  the  only  symptom  of  the  affection  of  the 
orbicularis. 

Causes. — The  cause  of  the  lesion  may  be  central  or  periph- 
eral. Of  the  latter,  exposure  to  drafts,  colds  and  injuries 
of  the  face  are  common;  of  the  central  causes,  syphilis  and 
middle  ear  diseases  are  the  most  frequent.     If  the  auditory 


192  DISEASES  AND  INJURIES  OF  THE  EYE. 

nerve  is  also  affected,  the  lesion  may  be  located  in  the  tem- 
poral bone  where  the  two  nerves  are  in  close  apposition.  The 
danger  to  the  eye  in  these  cases  is  from  exposure  of  the  cor- 
nea which  may  become  ulcerated. 

Treatment. — To  prevent  danger  to  the  cornea  plaster  strips 
may  be  used  to  close  the  eye.  At  night  closure  of  the  lids 
with  the  pressure  of  the  fingers  will  be  sufficient  to  retain 
them  in  their  position  during  sleep.  The  faradic  current  with 
the  negative  to  the  neck  and  the  positive  to  the  muscle  for  ten 
minutes  daily  may  be  sufficient.  The  internal  administration 
of  Caust.,  Bell.,  Nux  or  Zinc,  may  be  beneficial  in  some  cases. 

BLEPHAROSPASM. 

Spasm  of  the  orbicularis  is  usually  reflex  from  some  corneal 
or  conjunctival  irritation  and  inflammation.  It  may  be  either 
clonic  or  tonic. 

Nictitation,  or  frequent  winking,  is  a  clonic  variety  of 
blepharospasm  and  consists  of  simple  twitching  or  winking 
which  is  confined  to  the  eyelids,  and  may  be  congenital  or 
result  from  some  hypersemic  or  granular  condition  of  the  con- 
junctiva, refractive  error,  or  from  a  diseased  tooth.  The  cause 
as  far  as  possible  must  be  removed,  the  general  tone  improved, 
and  when  idiopathic  it  will  oftentimes  be  relieved  by  the  use 
of  Agar.,  Physostig.,  Ignat.  and  Hyosc. 

Blepharospasm  is  tonic  in  character  and  longer  in  duration 
than  the  other  variety.  It  arises  more  frequently  from  irrita- 
tion of  the  retina  or  branches  of  the  fifth  nerve  of  the  cornea, 
conjunctiva,  or  iris  by  light  and  accompanied  by  photophobia 
and  is  a  frequent  accompaniment  of  inflammatory  affections  of 
the  eye  in  scrofulous  or  debilitated  subjects,  but  may  be  due 
to  extraneous  causes,  as  exposure,  or  the  presence  of  foreign 
bodies  in  the  cornea  or  conjunctiva. 

Treatment. — When  idiopathic  or  chronic.  Agaric,  Gels., 
and  Conium  will  relieve  some   cases.     If    the  refraction  is 
found  anomalous,  proper  glasses  are  to  be  worn.     Division  of 
the  supra-orbital  nerve  may  be  indicated  in  other  cases,  where  . 
there  is  sensitiveness  at  the  exit  of  the  nerve. 


BLEPHAROSPASM— ECZEMA.  193 

I  have  relieved  some  cases,  occurring  in  strumous  children 
with  conjunctival  or  corneal  affections,  by  the  use  of  ice  bags 
applied  to  the  eyes  for  one  or  two  hours  per  day.  The  topical 
application  of  ice-water  has  also  been  recommended  to  relieve 
the  spasm.  Division  of  the  outer  canthus  may  become  neces- 
sary in  some  cases. 

Eczema  frequently  accompanies  phlyctenular  affections  of  the 
cornea  or  conjunctiva  in  children,  or  may  be  associated  with 
an  eczematous  eruption  of  the  face  or  behind  the  ears,  and 
requires  the  use  of  Graph.,  Hepar  sulph.,  Ars.,  Crot.  tig., 
Antim.  crud.,  Mez.,  Sepia,  Lycop.  and  Tell.,  according  to  the 
indications  necessary  for  similar  eczemas  of  other  parts. 

Herpes  Zoster  is  an  affection  of  the  nervous  apparatus 
depending  upon  irritation  of  tha  Gasserian  ganglion  or  sensory 
root  of  the  fifth  nerv-e.  There  is  severe  neuralgic  pain  involv- 
ing one  side  of  the  forehead,  eyelids,  eye,  and  perhaps  the 
face.  The  skin  becomes  swollen  and  red,  with  herpetic  vesi- 
cles upon  the  surface.  These  soon  form  hard  crusts  which 
leave  depressed,  red  scars.  The  eruption  may  not  be  confined 
to  the  eyelids  but  appears  upon  the  conjunctiva  or  cornea, 
where  it  becomes  exceedingly  dangerous,  and  other  complica- 
tions of  the  eyes  occur.  It  may  appear  at  any  age  but  more 
frequently  in  the  latter  years  of  life.  Tt  is  very  protracted  in 
its  course  and  months  may  elapse  before  the  disease  disap- 
pears. 

Treatment  consists  in  the  relief  of  the  pain,  which  is 
frequently  the  most  urgent  symptom,  by  the  use  of  narcotics. 
Graph.,  Arg.  nit.,  and  Ars.  may  be  the  remedies  indicated  in 
the  case.  In  two  cases  which  have  been  noted  by  the  WTiter, 
one  was  relieved  by  the  use  of  Arg.  nit,  and  the  other  by  Ars. 
In  both  cases  severe  scars  were  left  and  but  slight  destruction 
of  the  tissties  of  the  lid  occurred. 

Syphilitic  ulcers  of  the  lid  do  not  differ  in  appearance 
from  those  occurring  in  other  parts  of  the  body,  but  are 
frequently  destructive  to  large  portions  of  the  lid. 

Lupus  of  the  lid  may  occur  as  a  primary  affection  or  extend 
from  the  face.  It  may  continue  for  years,  healing  at  times,  lo 
13 


194  DISEASES  AND  INJURIES  OF  THE  EYE. 

again  re-open,  and  there  is  usually  a  dark  crust  whicli  covers 
the  ulceration,  and,  when  removed,  exposes  a  raw,  bleeding  sur- 
face. Phytolacca  internally  and  externally  has  undoubtedly 
relieved  some  cases  of  lupoid  growth,  but  incision  is  ad\dsed 
when  the  disease  is  not  too  extensive. 

Epithelioma  is  usually  more  rapid  in  its  destructive  process 
than  lupus  and  may  ulcerate,  and  infiltration  of  the  lymphatics 
in  front  of  the  ear  frequently  exists  in  the  latter  stages  of  the 
disease.  Complete  excision  is  the  proper  remedy,  and  a  ble- 
pharoplastic  operation  should  follow. 

Xanthelasma  is  an  affection  of  the  lids  in  which  yellow, 
slightly  raised  patches  appear  near  the  inner  canthus,  which 
consist  of  a  deposit  of  fat  cells  in  the  skin,  and  are  supposed 
to  be  dependent  upon  some  disease  of  the  liver.  The  deform- 
ity may  be  relieved  by  an  operation  for  the  removal  of  the 
patches,  but  this  is  rarely  acceded  to  by  the  patient. 

N^vi,  WARTS  AND  MOLES  of  the  lids  do  not  differ  from  the 
same  affections  in  other  parts  of  the  body,  but  from  the  impor- 
tant structures  involved  require  early  removal. 

MoLLUSCA  are  small,  round  tumors  of  varying  size  which 
are  developed  in  the  follicles  of  the  skin  of  the  lid  and  face. 
A  slight  dimple  on  the  top  of  the  tumor  indicates  the  opening 
of  the  follicle  through  which  a  milky  fluid  often  extrudes 
which  is  supposed  to  be  capable  of  reproducing  the  disease. 
The  tumor  should  be  opened  and  the  albuminous  contents 
squeezed  out.  The  internal  and  external  use  of  Thuya  pro- 
duced marked  benefit  in  one  case  observed  by  the  author. 

CoLOBOMA  of  the  lid  is  a  congenital  fissure  of  the  same 
character  as  hare-lip.  It  is  treated  by  paring  the  edges  of  the 
lid  and  uniting  them  with  a  deep  suture. 

Epicanthus  is  a  term  applied  to  a  crescentic  fold  of  skin 
which  slightly  overlaps  the  inner  canthus  of  each  eye.  It  is 
congenital  and  usually  decreases  as  the  child  grows  and  the 
bridge  of  the  nose  develops.  In  extreme  cases  an  improve- 
ment may  be  obtained  by  the  removing  of  a  vertical  ellipse  of 
skin  from  the  bridge  of  the  nose  and  uniting  the  edges  of  the 
wound  by  sutures. 


ANCHYLOBLEPHARON— TUMORS.  195 

Anchyloblepharon  is  a  condition  in  wliich  the  lids  are 
adherent  to  each  other,  and  may  be  total  or  partial.  It  may 
be  congenital  or  caused  by  ulcerative  blepharitis  marginalis, 
or  result  from  burns  when  the  cornea  or  conjunctiva  is  also 
involved.  An  incision  may  be  made  along  the  line  of  union, 
and  the  separated  surfaces  smeared  with  cosmoline  or  painted 
with  collodion  to  prevent  their  adherence. 

Tumors  of  the  lid,  other  than  those  already  considered, 
require  incision,  and  in  operating  as  little  skin  should  be 
sacrificed  as  possible,  so  as  to  have  sufficient  cuticle  to  cover 
the  parts  without  stretching. 

Injuries  of  the  lid  have  already  been  considered  in  the 
chapter  devoted  to  Injuries  of  the  Eye. 


r 


CHAPTEE    X. 

DISEASES  OF  THE  CONJUNCTIVA. 

ANATOMY. 

The  conjunctiva  is  the  mucous  membrane  lining  the  lids;  it 
is  continuous  with  the  integument  at  their  margins  and  also 
with  the  mucous  membrane  lining  the  puncta,  canaliculi,  lach- 
rymal sac  and  duct,  and  is  reflected  back  upon  the  eyeball, 
covering  the  sclera  and  extending  slightly  upon  the  edge  of 
the  cornea.  It  consists  of  two  portions:  the  palpebral,  with 
which  may  be  included  the  plica  semilunaris  and  caruncula, 
and  the  ocular,  or  conjunctiva  bulbi,  in  which  may  be  distin- 
guished the  sclerotic  and  corneal  portions;  each  of  these  parts 
present  distinctive  characteristics.  The  epithelium  of  the 
conjunctiva  varies  somewhat  at  different  points,  but  is  mainly 
columnar,  with  small  cells  between  their  fixed  ends;  near  the 
skin  and  cornea  it  shades  off  into  the  stratified  epithelium 
which  covers  these  parts.  At  the  point  where  the  conjunctiva, 
is  reflected  from  the  lids  upon  the  eyeball  it  forms  a  fold, 
which  is  termed  a  cul-de-sac,  fornix,  or  retro-tarsal  fold,  or 
when  applied  to  the  upper  or  lower  lid,  the  superior  and 
inferior  palpebral  fold.  At  the  inner  canthus,  we  find  a  small 
rounded  eminence  termed  the  caruncle  which  consists  of  small 
glandular  bodies  containing  numerous  sebaceous  follicles  and 
some  fine  hairs;  toward  the  cornea  are  seen  small  crescentic 
folds  of  conjunctiva,  the  plica  semilunaris,  which  are  regarded 
as  a  rudimentary  development  of  the  third  eyelid  of  animals. 


DISEASES  OF  THE  CONJUNCTIVA.  197 

The  palpebral  portion  of  the  conjunctiva  is  thicker  and 
more  vascular  than  the  ocular,  and  presents  a  pale  salmon 
<jolor.  It  is  composed  of  columnar  and  flat  epithelium  fixed 
upon  a  connective  tissue  basis.  Although  closely  connected 
to  the  tarsi,  it,  however,  presents  numerous  minute  furrows 
and  folds  discernible  with  a  magnifying  lens,  which  give  to  it 
a  velvety  appearance.  Just  beyond  the  upper  border  of  the 
tarsus,  it  is  drawn  into  broad  folds  at  the  fornix;  in  these 
folds,  as  well  as  scattered  through  the  palpebral  conjunctiva, 
are  found  numerous  small  conjunctival  glands  which  secrete 
the  moisture  and  lubricating  material  which  keep  the  eye 
moistened,  and  are  of  more  importance  in  this  respect  than  the 
lachrymal  gland  whose  main  office  seems  to  be  to  flood  the 
eye.  The  retro-tarsal  folds  are  very  loosely  attached  to  the 
parts  beneath  and  are  of  a  darker  color  than  the  conjunctiva 
of  the  lids. 

The  ocular  conjunctiva  is  smoothly  but  loosely  attached  to 
the  eyeball  by  submucous  tissue.  It  is  transparent  and  but 
few  blood-vessels  are  seen  in  the  healthy  condition.  At  the 
margin  of  the  cornea,  the  conjunctiva  slightly  overlaps  the 
cornea  while  the  epithelial  layer  is  continuous  with  that  of 
the  cornea. 

The  blood-vessels  are  derived  from  the  palpebral  and  lachry- 
mal arteries.  The  nerves  are  branches  of  the  fifth  pair  and 
form  a  thick  plexus  from  which  terminal  filaments  are  very 
numerous  and  end  among  the  epithelium.  A  well-developed 
network  of  lymph  vessels  appears  throughout  the  sclerotic 
and  palpebral  portions  of  the  conjunctiva  and  communicates 
with  those  of  the  cornea. 

DISEASES  OF  THE  CONJUNCTIVA 

The  term  ophthalmia,  which  was  formerly  extensively  used, 
is  in  the  present  advanced  knowledge  of  ophthalmology 
applied  only  to  affections  of  the  conjunctiva,  and  as  it  describes 
no  particular  condition,  it  should  be  dropped  from  the  nomen- 
clature of  eye  diseases. 


198  DISEASES  AND  INJURIES  OF  THE  EYE. 

The  conjunctival  tissue  may  be  distended  by  an  effusion  of 
blood,  ecchymosis ;  of  serum,  chemosis ;  or  air,  emphysema ;  or 
be  subject  to  inflammation,  as  in  the  various  forms  of  conjunc- 
tivitis. 

Ecchymosis  is  occasioned  by  the  rupture  of  one  or  more  of 
the  capillaries  of  the  conjunctiva  from  injury,  as  during 
violent  coughing,  sneezing,  or  vomiting,  or  often  without  any 
assignable  cause.  The  effused  blood  appears  as  a  small  red 
patch  on  the  white  of  the  eye,  or  may  be  so  abundant  as  to 
entirely  cover  the  sclera  and  extend  up  to  the  edge  of  the 
cornea.  The  appearance  is  so  entirely  different  from  any 
inflammatory  affection  of  the  conjunctiva  that  it  is  not  easily 
mistaken.  Whether  the  extravasation  be  slight  or  great  it  is 
unimportant,  as  it  is  gradually  absorbed  and  dispersed  in 
from  one  to  three  weeks.  It  is  unsightly,  however,  and 
alarms  the  patient.  The  use  of  Hamamelis  and  Arnica 
locally,  and  the  same  remedies  internally,  cause  a  rapid 
absorption  of  tha  effused  blood  and  is  all  the  treatment  that  is 
necessary. 

Chemosis  or  oedema  of  the  conjunctiva,  is  a  symptom  which 
may  accompany  the  various  inflammatory  affections  of  the 
eyeball  or  its  appendages.  It  consists  of  an  effusion  of  serum 
between  the  conjunctiva  and  sclera,  and  results  whenever  the 
flow  of  blood  through  the  conjunctival  veins  is  impeded.  The 
conjunctiva  is  raised  up  and  appears  like  a  translucent,  jelly- 
like mass  which  may  overlap  the  cornea  or  extrude  between 
the  lids.  It  occurs  in  some  cases  as  the  result  of  exposure  of 
the  eye  or  side  of  the  face  to  a  draught,  as  when  traveling. 
It  is  not  infrequently  presented  by  elderly  people  with 
anaemia,  heart  or  kidney  disease,  and  a  relaxed  condition  of 
the  conjunctiva.  In  this  case  it  is  not  troublesome,  as  it 
disappears  in  a  few  hours  under  the  application  of  a  compress 
bandage  and  the  use  of  Apis  or  Arsenicum  internally.  When 
it  accompanies  inflammatory  diseases  of  the  cornea  it  becomes 
a  serious  complication,  and  injures  the  integrity  of  the  eye  by 
interfering  with  the  circulation  of  blood  through  the  tissues. 

Emphysema  is  a  rare  condition,  but  may  appear  after  inju- 


HYPERJEMIA— TREATMENT.  199 

ries  to  the  conjunctiva,  orbit,  or  operations  upon  the  lachrymal 
ducts.  The  conjunctiva  presents  a  colorless  swelling  which 
gives  a  slight  crackling  sensation  on  pressure.  The  applica- 
tion of  a  pressure  bandage  is  all  that  is  nececsary. 

HYPEREMIA. 

Hypersemia  of  the  conjunctiva  may  be  acute  or  chronic. 
The  acute  form  is  the  result  of  irritation,  and  disappears 
rapidly,  or  is  followed  by  an  inflammation.  A  chronic  hyper- 
semia  may  develop  slowly  or  follow  conjunctival  inflamma- 
tion and  persist  for  a  long  time. 

Causes. — The  causes  of  chronic  conjunctival  hyperaemia 
are,  exposure  of  the  eyes  to  irritating  gases,  smoke,  dust,  and 
bright  lights,  wounds,  confinement  in  an  impure  atmosphere, 
or  prolonged  use  of  the  eyes  in  a  dull  light  Any  of  these 
causes,  if  not  sufficient  in  degree  or  amount  to  produce  an 
active  inflammation,  when  continuous  in  their  action  produce 
a  chronic  condition.  Other  fruitful  causes  are,  errors  of  refrac- 
tion, as  hyperopia,  astigmatism  and  beginning  myopia,  which 
produce  eye  strain,  and  also  nasal  catarrh.  The  hyperaemia  is 
usually  confined  to  the  lid  portions  of  the  conjunctiva  and  has 
been  termed  palpebral  conjundivUis. 

Symptoms. — The  symptoms  of  hyperaemia  are,  injections  of 
the  arterioles  of  the  conjunctiva,  especially  of  the  lids,  the 
development  of  papilliform  eleA'ations  at  the  edges-  of  the 
tarsus  and  in  the  retro-tarsal  folds,  and  an  increased  secretion 
of  tears  on  using  the  eyes,  with  itching,  pricking,  sandy,  dry 
or  hot  sensations,  especially  when  the  eyes  are  used  for  near 
work. 

Treatment. — The  removal  of  the  cause  is  absolutely  neces- 
sary. The  eye  should  be  examined  for  ametropia  and  glasses 
adapted  and  worn  when  refractive  errors  are  discovered. 
Temporary  relief  may  be  obtained  by  the  use  of  cold  water. 
Bathe  the  eyes  in  a  weak  solution  of  salt  and  water,  or  allow  a 
stream  of  water  to  play  over  the  closed  eyelids  for  a  few 
minutes  daily.     If  a  weak  collyrium  is  desired,  sodae-biboratis 


200  DISEASES  AND  INJURIES  OF  THE  EYE. 

gr.  yiii  ad  £3!,  or  acid,  boracic.  gr.  v  ad  £3!  will  be  benefi- 
cial. Internally,  the  administration  of  Aeon,,  Gels,  Ars., 
Euphrs.,  Bell.,  Causi,  Dubois.,  Graph.,  Merc,  sol.,  Nux, 
Sepia,  and  Sulph.  may  be  called  for.  A  careful  consideration 
should  also  be  given  the  remedies  and  their  indications  as 
mentioned  under  Muscular  Asthenopia. 

CONJUNCTIVITIS. 

It  is  important  to  learn  to  distinguish  the  various  forms  of 
inflammation  of  the  conjunctiva  from  each  other,  and  from 
deeper  affections  of  the  eyeball.  The  characteristic  features 
of  inflammation  are  hypersemia,  or  enlargement  of  the  vessels, 
and  a  discharge  which  may  consist  of  tear  fluid  mixed  with 
epithelial  cells,  mucous  or  pus;  in  the  deeper  inflammatory 
affections,  chemosis,  hypertrophy  of  the  papillae,  thickening 
of  the  mucous  membrane  from  hypertrophy  of  the  connective 
tissue  elements,  increase  of  the  lymph  follicles  or  new  deposits 
of  lymph  corpuscles. 

In  inflammations  of  the  cornea,  iris,  and  some  other  tissues 
of  the  eyeball,  the  vessels  appear  deeper,  straighter  and  move 
pinkish  or  purplish,  and  do  not  move  with  the  Aaovements  of 
the  conjunctiva. 

Conjunctivitis  may  present  several  varieties  dependent  upon 
the  cause,  grade  of  inflammation,  and  character  of  the 
discharge,  and  one  variety  may  pass  into  another,  or,  the  two 
forms  exist  at  the  same  time.  The  varieties  of  inflammation  are 
divided,  from  a  clinical  rather  than  a  pathological  standpoint, 
into  catarrhal  or  simple;  purulent,  which  includes  ophthalmia 
neonatorum,  gonorrhoeal,  croupous,  diphtheritic  and  tra- 
chomatous; and  follicular  and  phlyctenular.  All  varieties 
present  secretions  which  are  more  or  less  contagious,  and 
when  introduced  into  the  eye  may  occasion  an  inflammation  of 
the  same  form  from  which  the  contagion  is  derived,  or  excite 
another  variety  of  conjunctivitis.  Hence  the  utmost  care 
should  be  used  to  prevent  the  spread  of  the  contagion,  and 
when    conjunctival   diseases   occur    endemically  in  hospitals, 


PLATE  11  ' 


Purulent   Conjunctivitis 
(  First   StacjC) 


Phlyctenular  Conjunctivitis 


Pur'u.G.,.  ..v.junctiviHs 
(Second  Statue) 


Granulated  Lids 


Pterygium 


CONJUNCTIVITIS  CATARRHALIS. 


201 


asylums,  and  other  public  institutions,  isolation  and  the  utmost 
cleanliness  should  be  practiced  in  order  to  limit  the  extent  of 
the  epidemic ;  the  disease,  however,  may  be  propagated  by  the 
atmosphere  where  the  rooms  are  over-crowded  and  the  venti- 
lation poor. 

CONJUNCTIVITIS  CATARRHALIS. 

Catarrhal  or  simple  conjuncti^-itis  is  characterized  by  an 
injection  of  the  vessels  of  the  conjunctiva;  it  may  be  confined 
mostly  to  the  lid  portions  or  involve  the  whole  extent  of  the 
conjunctiva,  which  becomes  red  from  the  injection.  (Plate 
II ,  Fig.  1. )  The  papillary  layer  swells  and  more  or  less  loss 
of  epithelium  occurs. 

Symptoms. — The  secretion  is  increased  and  contains  mostly 
mucus  and  tears ;  later  some  pus  cells  appear  and  the  discharge 
becomes  muco-purulent.  Small  spots  of  ecchymosed  blood 
in  the  ocular  subconjunctival  tissue  are  very  common  and 
characteristic  of  catarrhal  conjunctivitis.  The  eyes  appear 
suffused  and  the  tears  may  run  over  the  lids,  and,  if  acrid, 
excoriate  the  cheeks;  during  the  night,  from  evaporation 
of  the  more  fluid  portions  of  the  discharge,  the  mucus  thickens 
and  collects  upon  the  cilia  and  upon  the  edges  of  the  lid  and 
gluing  them  together  makes  it  difficult  to  open  the  eyes  in  the 
morning  until  water  is  applied.  If  the  attack  is  severe  the 
conjunctiva  becomes  more  swollen,  but  remains  smooth;  in 
some  cases  chemosis  may  be  present  and  occasionally  some 
febrile  excitement.  The  patient  complains  of  a  scratching,  or 
sandy  feeling,  or  as  if  the  eye  was  full  of  sticks.  A  very 
common  sensation  is  that  of  a  foreign  body  under  the  upper 
lid  and  it  is  often  a  very  difficult  matter  to  satisfy  the  patient 
that  such  is  not  the  case,  even  after  the  lid  has  been  everted 
and  the  surgeon  has  determined  that  there  is  nothing  but  the 
inflamed  conjunctiva  to  be  dealt  with.  In  some  of  these  cases 
temporary  relief  occurs  from  the  removal  of  a  bit  of  stringy 
discharge  which,  from  the  motion  of  the  eye,  has  been  rolled 
into  a  thread-like  mass  and  remains  under  the  lid.     Bright 


202 


DISEASES  AND  INJURIES  OF  THE  EYE. 


lights  become  disagreeable  and  artificial  light  at  night  aggra- 
vates the  condition  of  the  eyes.  The  vision  is  sometimes  made 
temporarily  dim  or  foggy  by  the  increased  discharge  passing 
over  the  cornea,  and  momentary  relief  comes  fi'om  winking. 
In  the  more  chronic  forms  the  gluing  together  of  the  lids  in 
the  morning,  the  sandy  feeling  and  aggravation  from  artificial 
light,  and  perhaps  an  itching  or  excoriation  of  the  lids  are  all 
that  is  usually  complained  of. 

Causes. — The  causes  of  catarrhal  conjunctivitis  are  very 
numerous.  It  more  frequently  arises  from  the  presence  and 
irritation  of  foreign  bodies:  the  exposure  of  the  eyes  to  cold, 
irritating  vapors,  dust,  or  chemical  irritants,  vitiated  air,  or 
sudden  atmospheric  changes.  It  is  a  frequent  accompaniment 
of  acute  or  chronic  nasal  catarrhs,  inflammation  of  the  lach- 
rymal sac  and  blepharitis,  and  may  be  the  result  of  eye  strain 
in  errors  of  refraction.  It  frequently  appears  during  the 
eruption  in  scarlatina,  measles  and  small-pox,  and  some 
chronic  cases  appear  from  the  lax  condition  of  the  orbicularis 
which  allows  the  entrance  of  air  between  the  conjunctival 
surfaces  of  the  lid  and  ball ;  and  in  other  cases  as  a  result  of 
the  alcoholic  habit.  All  inflammatory  diseases  of  the  eye, 
except  perhaps  retinal  or  optic  nerve  affections,  may  occasion 
conjunctivitis. 

Diagnosis  and  Prognosis. — The  diagnosis  becomes  difficult 
in  many  cases;  the  discharge  will,  however,  differentiate  it 
from  other  forms  of  conjunctivitis  and  from  more  deep-seated 
eye  diseases,  while  the  transparency  of  the  cornea  will  not 
render  it  likely  to  be  mistaken  for  corneal  affections.  The 
accumulation  of  the  dried  discharge  on  the  lids  may  make  it 
liable  to  be  confounded  with  blepharitis,  but  the  easy  removal 
of  the  discharge,  the  clear  condition  of  the  skin,  and  absence 
of  thickening  of  the  lid  edge  will  clear  up  all  doubts.  A 
chronic  catarrhal  conjunctivitis  may  be  consequent  upon 
simple  conjunctivitis  where  the  habits,  low  condition  of  the 
health,  and  long-continued  use  of  the  eyes  at  fine  work, 
prevent  a  perfect  restoration  of  the  inflamed  conjunctiva.  The 
eye  has  a  reddish,  irritable    condition,   and   the    conjunctiva 


CONJUNCTIVITIS  CATARRHALIS— REMEDIES.  203 

becomes  thickened  and  produces  an  increased  mucous  secre- 
tion. There  is  agglutination  of  the  lids  in  the  morning,  or 
accumulation  of  dried  secretion  in  the  inner  canthi.  The 
thickening  of  the  conjunctiva  of  the  lower  lid  is  apt  to  cause 
eversion  of  the  lid,  displacement  of  the  punctum  and  overflow 
of  tears  which  reddens  or  glazes  the  lid  margins.  The  disease 
is  often  obstinate  and  may  persist  for  a  long  time,  and  causes 
much  discomfort  by  itching,  watering,  and  irritation  of  the 
eye  on  attempting  to  read  or  do  fine  work. 

Treatment  must  be  directed  in  the  first  place  toward  the 
removal  of  all  hurtful  influences.  Many  cases  recover  without 
attention  of  any  kind.  When  occurring  during  the  progress 
of  an  eruptive  disease  it  usually  requires  no  special  treatment 
beyond  a  moderate  exclusion  of  the  light;  other  cases  disap- 
pear on  the  removal  of  the  exciting  cause.  The  possibility  of 
a  foreign  body  being  still  present  beneath  the  lid  must  be 
remembered,  the  lid  everted,  and  any  foreign  substance 
removed.  In  chronic  cases  inquiry  in  regard  to  the  habit  and 
diet  will  be  necessary,  and  a  better  hygienic  condition  should 
be  recommended,  with  a  good  and  plentiful  diet,  pure  air,  and 
the  avoidance  of  all  alcoholic  or  malt  liquors,  particularly 
before  retiring. 

The  remedial  treatment  consists  in  the  judicious  selection 
of  remedies  according  to  indications,  the  topical  use  of  ice, 
and  if  desired,  a  weak  astringent  collyrium  of  borax  gr.  x, 
boracic  acid  gr.  v,  or  sulphate  of  zinc  gr.  i,  ad  fjj  of  rose 
water,  or  camphor  water,  may  be  employed  with  benefit. 

REMEDIES. 

Aconite. — Indicated  in  the  beginning  of  conjunctival  inflam- 
taation,  particularly  those  forms  arising  from  foreign  bodies 
and  from  exposure  to  cold  or  dry  winds.  The  conjunctiva  is 
injected,  perhaps  chemotic,  hot  and  feels  dry,  while  the  pain 
is  often  very  severe  or  more  of  an  aching  character,  with  a 
sensation  as  if  the  eyeball  was  too  large. 


204 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Belladonna. — About  the  same  condition  is  presented  as  in 
Aconite  but  there  is  usually  more  photophobia  and  concomi- 
tant headache,  flushed  face,  etc.,  which  will  distinguish  it  from 
Aconite  during  first  stage. 

Euphrasia. — Frequently  indicated  in  both  the  acute  and 
chronic  forms.  The  conjunctiva  appears  very  red  and  occa- 
sionally chemotic.  The  lachrymation  in  the  early  stage  is 
profuse  and  acrid,  while  later,  the  discharge  is  profuse, 
muco-purulent,  yellowish,  and  excoriates  the  lids  and  cheek. 
In  other  cases  the  discharge  is  very  slight  and  blurs  the  vision 
by  partially  covering  the  cornea  which  is  again  cleared  tempo- 
rarily by  winking. 

Mercuriiis.  —  Yery  useful  in  various  acute  or  chronic 
catarrhal  affections,  especially  Merc.  sol.  or  cor.  The  lachry- 
mation is  profuse,  burning  and  acrid,  and  the  mucous  dis- 
charge also  burning  and  excoriating.  There  is  usually  marked 
general  redness  of  the  conjunctiva  and  aggravation  from 
artificial  light.  The  condition  is  frequently  aggravated  at 
night*and  from  cold  damp  weather.  The  pains  are  variable 
and  there  is  not  infrequently  neuralgic  pains  in  the  forehead 
and  temple. 

Pulsatilla.— J] s,ei\)l  in  both  acute  and  chronic  varieties.  The 
conjunctival  hypersemia  is  not  usually  intense.  The  pains 
may  be  burning,  itching,  or  stinging  and  aggravated  in  a  close 
hot  room  and  in  the  evening,  and  are  often  relieved  by  the 
cool  open  air.  The  discharge  is  generally  bland,  whitish  and 
muco-purulent  and  glues  the  lids  together  during  the  night. 

Sulphur. — Often  indicated  in  both  the  acute  and  chronic 
forms.  The  pains,  redness  and  swelling  of  the  lids  are  vari- 
able. The  sensations  are  usually  as  if  the  eyes  were  full  of 
sand  or  sticks,  or  burning  and  dry.  Fine,  sharp,  darting 
pains  through  the  eye  are  very  characteristic. 

Many  other  remedies  may  be  occasionally  useful,  as  Allium 
cep..  Alum.,  Apis  mel.,  Arsenicum,  Arg.  nit..  Chloral,  Graph., 
Hepar  s..  Ipecac,  Ignat.,  Nux  vom.,  Nat.  mur.,  Rhus  tox., 
Sepia  and  Terebinth. 


VERNAL  CONJUNCTIVITIS.  205 

VERNAL  OR  AUTUMNAL  CONJUNCTIVITIS. 

In  tlie  spring  during  the  months  of  April  and  May,  or  in- 
the  fall  during  September  of  each  year,  an  aggravated  form  of 
catarrhal  conjunctivitis,  which  is  more  or  less  epidemic, 
appears  in  some  localities,  and  seems  to  bear  some  close  rela-^ 
tion  to  the  cause  of  rose  colds  and  hay  fever,  and  would  also- 
appear  to  depend  upon  atmospheric  conditions. 

Symptoms.  —  The  affection  usually  commences  with  an 
itching  or  pricking  sensation  of  the  conjunctiva  at  the  inner 
canthus,  and  may  affect  only  the  conjunctiva  at  that  point;  or 
intense  heat  of  the  lid,  and  redness  and  swelling  of  the  con- 
junctiva with  a  more  or  less  muco-purulent  discharge  may 
follow,  together  with  more  or  less  intolerance  of  light. 

The  marked  feature  of  these  cases  seems  to  be  the  paroxys- 
ijial  itching  and  burning  which  occasions  irresistible  rubbing 
of  the  eyes,  and  this  increases  the  irritation  causing  a 
saudy  or  scratching  sensation.  The  tears  or  mucus  which  are 
poured  out  abundantly  excoriate  the  cheek,  and  the  lids  may 
become  swollen,  red  and  oedematous.  There  is  commonly  more 
or  less  sneezing  and  nasal  irritation  which  may  be  the  initial 
symptom  of  an  attack  of  rose  cold  or  hay  fever.  The  treat- 
ment is  usually  simple  and  requires  the  use  of  Aconite,  Merc. 
sol.,  Euphras.,  or  Sulph.,  with  the  topical  application  of  a 
collyrium  of  borax. 

There  is  another  form  of  conjunctival  infiltration  termed 
spring  catarrh  of  the  conjunctiva,  which  is  entirely  different 
tjom  that  already  described,  in  that,  there  is  the  conjunctival 
bitiltration  (Von  Graefe),  or  a  hypertrophy  (Saemish,  Burnett) 
of  the  conjunctiva  over  the  ciliary  region  at  the  periphery  of 
the  cornea.  The  appearance  is  somewhat  similar  to  the  phlyc- 
tenules of  the  conjunctiva  when  forming  a  circle  at  this  point. 
The  conjunctiva  is  elevated  and  nodular  or  mound-like,  or 
simply  thickened.  The  extent  of  the  infiltration  may  be  from 
one  to  three  mm.  in  width,  and  the  conjunctiva  of  the  bulb 
only  slightly,  if  at  all,  injected.  Changes  occur  in  the  corneal 
margin    and    in    negroes   the   infiltration    is    often   markedly 


206  DISEASES  AND  INJURIES  OF  THE  EYE. 

pigmented.  Wanstall,  of  Baltimore,  gives  a  report  of  cases 
observed  by  him  and  a  resume  of  the  literature  of  the  subject 
in  the  Transactions  of  the  Horn.  O.  and  O.  Soc.  18S0-1882. 
The  disease  persists  for  months,  but  may  finally  disappear; 
local  treatment  is  not  indicated  and  Wanstall  reports  Merc, 
prot.  as  efficacious  in  the  treatment  of  the  disease.  This 
affection  has  undoubtedly  been  mistaken  for  the  ring  form  of 
phlyctenular  inflammation  occurring  at  the  margin  of  the 
cornea. 

ATROPINE  CONJUNCTIVITIS. 

A  form  of  irritation  and  inflammation  of  the  conjunctiva  is 
occasioned  not  infrequently  by  the  instillation  of  atropine, 
particularly  in  old  people,  and  in  some  cases  which  do  not 
seem  to  tolerate  the  use  of  atropine,  which  causes  pain,  smart- 
ing or  itching  when  introduced.  The  conjunctiva  becomes 
hypersemic,  thickened,  injected,  or  roughened,  and  apparently 
granular,  and  there  is  either  a  secretion  of  tears  only,  or  tears 
and  mucus  combined.  The  lids  may  be  swollen  or  become 
hyperaemic,  glazed  or  excoriated.  The  use  of  atropine  should 
be  discontinued  and  some  other  mydriatic,  as  duboisia,  substi- 
tuted. The  discontinuance  of  the  atropine  and  the  use  of  a 
weak  coUyrium  of  borax  or  boracic  acid  will  be  all  that  is 
necessary.  Where  it  seems  desirable  to  use  the  atropine  the 
addition  of  borax  or  boracic  acid  to  the  atropine  solution  will 
sometimes  prevent  the  irritation  from  the  use  of  the  drug. 

CONJUNCTIVITIS  PURULENTA. 

Blennorrhoeaic  inflammation  of  the  conjunctiva  is  much 
more  severe  and  dangerous  than  the  catarrhal  or  simple  form 
of  inflammation. 

Causes. — It  may  be  idiopathic,  or  result  from  specific  infec- 
tion, or  from  inoculation  by  muco-purulent  or  purulent  dis- 
charges from  any  form  of  conjunctivitis. 

Symptoms  and  Diagnosis.— It  is  characterized  by  a  profuse 
di|^harge  of  pus,  and  tense  swelling  of  the  conjunctiva.     The 


CONJUNCTIVITIS  PURULENTA— PROGNOSIS.  207 

chemosis  is  a  marked  feature  of  the  disease,  and  if  the  conjunc- 
tiva is  at  all  lax  the  swollen  membrane  extrudes  between  the 
lids,  puffs  out  as  the  patient  looks  downward,  or  overlaps  the 
cornea  like  a  circular  cushion.  The  surface  of  the  conjunctiva 
is  generally  smooth,  bright  red,  tense  and  glistening,  or  in 
severe  cases  has  a  grayish  or  tawny  color  due  to  the  fibrinous 
exudation  into  the  subconjunctival  tissue.  The  eyelids  also 
become  hard,  thickened  and  present  a  livid  appearance,  while 
the  upper  lid  becomes  much  increased  in  size  and  hangs  down 
over  the  lower  lid  and  is  only  capable  of  slight,  or  no  elevation 
by  the  levator  muscle.  The  secretion  is  thin  and  serous,  or 
tinged  with  blood  at  first,  often  flaky,  and  running  over  the 
lid  excoriates  the  cheek.  After  a  few  hours,  or  days,  the 
discharge  becomes  markedly  purulent;  at  this  stage  the 
appearance  of  the  conjunctiva  changes,  it  loses  its  glistening 
tense  appearance,  becomes  more  velvety,  and  presents  numer- 
ous uneven  folds  from  a  hypertrophied  condition  of  the  tissue 
itself.  The  discharge  is  now  a  thick,  creamy  pus,  and 
abundant. 

Prognosis.  —  The  prognosis  is  doubtful  as  regards  the 
vision  until  the  swelling  has  subsided,  as  the  great  danger  in 
cases  of  purulent  conjunctivitis  is  that  the  cornea  ■will  become 
implicated  in  the  disease.  During  the  first  stage  the  cornea 
usually  remains  intact,  but  when  the  chemotic  swelling  is  at 
its  height,  or  as  the  disease  begins  to  decline,  the  corneal 
danger  becomes  very  great.  The  corneal  complications  are 
either  marginal  ulcerations,  which  may  be  transparent,  puru- 
lent infiltration  of  its  tissue,  or  complete  suppuration  and 
necrosis.  As  a  rule,  the  later  the  corneal  affection  appears 
the  more  readily  it  responds  to  treatment. 

The  disease  may  be  acute  and  run  its  course  in  six  or  eight 
weeks,  and  recovery  take  place  without  serious  damage  to 
vision  and  the  mucous  membrane  return  to  its  normal  condi- 
tion. In  the  majority  of  cases,  however,  if  not  properly 
treated,  there  is  either  loss  of  vision  from  corneal  implication, 
or  the  disease  becomes  chronic  and  hypertrophy  of  the  con- 
junctiva and  development  of  granulations  result.  ^ 


208  DISEASES  AND  INJURIES  OF  THE  EYE. 

Treatment. — The  treatment  consists  in  the  utmost  cleanli- 
ness, the  constant  and  frequent  removal  of  the  discharge  ue  it 
forms;  the  application  of  cold  compresses,  preferably  the  uso 
of  ice  bags ;  if  but  one  eye  is  affected,  in  protecting  the  otlier 
from  infection  by  covering  the  eye  as  recommended  in  gonor- 
rhceal  ophthalmia;  and  the  use  of  the  proper  medical  remedy 
and  such  local  adjuvants  as  may  be  useful  in  the  different 
varieties. 

According  to  the  age  and  the  contagion,  purulent  conjuncti- 
vitis has  been  divided  into  blennorrhoea  of  new-born  babes  or 
ophthalmia  neonatorum,  and  gonorrhoeal  conjunctivitis j  clinic- 
ally, these  varieties  present  little,  if  any,  difference  from  the 
ordinary  form  of  purulent  conjunctivitis,  except  perhaps  a 
peculiar  malignity  in  some  cases. 

REMEDIES. 

Aconite  or  Bell,  may  be  indicated  in  the  first  stage  according 
to  the  symptoms  given  under  catarrhal  inflammation. 

Arg.  nit. — The  most  useful  remedy  for  any  form  of  purulent 
inflammation  as  soon  as  the  discharge  has  become  established. 
There  are  no  marked  symptoms  to  indicate  its  use  beyond 
those  which  characterize  the  blennorrhoeaic  process,  as  the 
swollen  lids,  chemotic  conjunctiva  and  profuse  creamy 
discharge. 

Pulsatilla. — This  remedy  is  next  in  importance  in  the  puru- 
lent form  of  inflammation  of  the  conjunctiva,  and  is  often 
more  useful  than  Arg.  nit.  in  the  latter  part  of  the  purulent 
stage,  or  when  the  latter  remedy  seems  to  have  lost  its  effect. 

Rhus  tox. — In  some  cases  of  ophthalmia  neonatorum  where 
there  is  severe  redness  and  oedema  of  the  lids  which  are  spas- 
modically closed  so  that  the  eye  is  opened  with  difficulty. 

Chamomilla.  —  Sometimes  useful  when  the  conjunctiva 
bleeds  easily,  or  there  is  blood  mingled  with  the  discharge, 
and  the  general  symptoms  of  the  remedy  are  present. 

Calc.  hyj^erphos. — Indicated  in  cases  where  there  is  faulty 
nutrition  and  where  sloughing  of  the  cornea  has  begun. 


OPHTHALMIA  NEONATORUM.  209 

Hepar  sulph. — May  be  indicated  when  tlie  discharge  is 
lessened,  or  the  cornea  becomes  involved,  or  hypopyon  has 
occurred. 

Mercurius. — This  remedy  is  indicated  in  the  later  stages  of 
the  disease,  when  the  discharge  has  become  thin  and  excoriat- 
ing, or  when  there  is  inflammation  of  the  cornea. 

OPHTHALMIA  NEONATORUM. 

Blennorrhoeaic  or  purulent  conjunctivitis  of  new-born  infants, 
is  an  inoculated  form  of  inflammation  of  the  conjunctiva,  and 
when  occurring,  as  it  does  very  frequently,  within  three  or 
four  days  after  birth,  indicates  an  infection  at  that  time,  or 
immediately  afterward. 

There  are,  however,  other  eye  troubles  of  infantile  life 
which  do  not  take  on  a  purulent  form  of  inflammation  and  are 
not  so  serious,  as  they  present  the  symptoms  of  simple  con- 
junctivitis and  require  only  attention  to  cleanliness  for  their 
relief.  This  fact,  however,  should  not  prevent  the  attending 
physician  from  making  a  personal  examination  of  the  condi- 
tion, as  these  apparently  simple  cases  may  continue  for  weeks 
without  much  increased  discharge,  and  the  condition  pass  into 
one  simulating  granular  lids  or,  more  properly, .  hypertrophy 
of  the  papillae  of  the  conjunctiva  of  the  folds  and  lids.  The 
prescription  of  Aconite,  Puis,,  Cham.,  and  Sulphur  may  be  of 
service  to  relieve  this  condition  when  detected  early.  If  a 
wash  is  demanded,  the  use  of  borax  or  boracic  acid  solutions 
for  washing  the  eyes  several  times  a  day  and  the  application 
of  cosmoline  to  the  lid  edges  is  all-sufficient  to  clear  up  these 
cases  rapidly. 

The  early  recognition  of  the  purulent  form  of  conjunctivitis 
is  of  the  utmost  importance  as  regards  treatment  and  results, 
and  when  promptly  recognized  and  properly  treated  the  prog- 
nosis should  be  extremely  favorable. 

Causes. — The  disease  appears  generally  from  the  second  to 
the  sixth  day  and  when  occurring  during  this  period  is  un- 
doubtedly caused  by  direct  local  inoculation,  either  from  the 
14 


210 


DISEASES  AND  INJURIES  OF  THE  EYE. 


gonorrhoeal,  or  leucorrhoeal  discharge  of  the  mother,  during 
the  passage  of  the  child  into  the  world.  As  a  rule  the  more 
virulent  the  inoculating  pus,  the  more  early  does  the  affection 
appear  and  the  more  violent  the  inflammation  following. 
Where  the  disease  appears  after  the  first  week  of  the  child's 
life,  other  causes  must  be  assigned  for  the  affection.  A  small 
percentage  of  cases  are  undoubtedly  due  to  the  manual  trans- 
fer of  infected  material  by  a  careless  nurse  or  mother ;  but  such 
local  irritants  as  cold,  foreign  bodies;  chemical  irritants  such 
as  soap,  as  well  as  atmospheric  causes,  also  hold  a  causative 
relation  to  this  disease. 

Prophylaxis.  —  Among  the  prophylactic  measures  which 
should  be  exercised  where  we  have  reason  to  suspect  this 
trouble,  are  first,  those  directed  to  the  mother,  and  second, 
those  to  the  child.  When  the  mother  presents  an  acrid  leucor- 
rhoeal or  gonorrhoeal  discharge,  or  a  vaginal  discharge  of  what- 
ever character,  the  most  scrupulous  attention  should  be  given 
to  its  correction  prior  to  confinement.  The  use  of  cleansing 
lotions  of  large  quantities  of  warm  water,  containing  carbolic 
acid,  boracic  acid,  sulphate  of  zinc,  or  glycerol e  of  tannin,  for 
several  days  prior  to  confinement  will  undoubtedly  lessen  the 
danger  of  infection.  After  the  birth  of  the  child  and  before 
the  cord  is  severed,  the  physician  should  at  once  cleanse  the 
eyelids  with  bits  of  soft  linen,  or  absorbent  cotton ;  remove  all 
secretion  from  the  cilia,  and  wash  the  eyelids  and  surrounding 
parts  in  a  weak  solution  of  boracic  acid. 

When  we  have  reason  to  suspect  that  the  danger  of  inocula- 
tion is  probable,  we  should,  as  soon  as  the  child  has  been 
otherwise  cared  for,  evert  the  lids  to  discover  and  remove  any 
of  the  unctuous  leucorrhoeal  discharge  which  may  have  insinu- 
ated itself  beneath  the  lid  and  found  a  resting  place  upon  the 
folds  of  the  conjunctiva. 

Symptoms  and  Diagnosis.  —  The  most  typical  cases  of 
ophthalmia  neonatorum  occur  from  twelve  to  seventy  hours 
after  birth.  Usually  before  the  third  day  we  find  the  eyelids 
somewhat  reddened,  slightly  swollen  and  a  slight  flow  of  tears. 
Eversion  of  the  lids  will   show  bright  red   transverse   lines 


OPHTHALMIA  NEONATORUM.  211 

occupying  the  middle  of  the  palpebral  conjunctiva;  shortly- 
after  this,  the  edges  and  angles  of  the  lids  become  red  and 
pel  haps  painful  on  pressure.  The  ocular  conjunctiva  is  next 
to  become  involved ;  it  appears  bright  red,  and  the  swelling  of 
the  lids  increases.  The  discharge  which  at  first  was  almost 
entirely  of  tears,  now  becomes  serous  and  gradually  assumes 
the  appearance  of  turbid  whey.  There  is  considerable  photo- 
phobia which  causes  the  infant  to  close  the  lids  tightly  so 
that  some  difficulty  is  experienced  in  opening  them.  This 
closes  the  first  stage.  The  second  stage,  or  that  of  suppuration 
is  ushered  in  usually  by  a  marked  increase  in  the  swelling  of 
the  lids.  This  swelling  increases  so  rapidly  that  often  in  twenty- 
four  hours  they  cannot  be  separated  without  considerable 
force.  The  upper  lid  usually  overlaps  the  lower  one  and,  in 
most  cases,  is  so  stifi"  that  it  is  difficult  or  impossible  to  turn  it. 
On  separating  the  lids  the  exposed  conjunctiva  is  thickened, 
perhaps  raised  in  folds,  and  of  a  diffused  bright  red  hue 
through  which  the  sclera  can  be  dimly  seen.  At  first  there  is 
a  muco-purulent  coating  over  the  entire  conjunctival  surface ; 
the  discharge  soon  becomes  more  abundant  and  decidedly 
purulent,  and  later  is  thick  and  creamy.  The  effusion  of  the 
conjunctiva  is  generally  serous  and  causes  chemosis  and  pro- 
trusion of  the  lids,  but  in  some  cases  contains  much  fibrin, 
and  the  conjunctiva  presents  a  raised  and  resisting  surface; 
this  condition  arises  more  particularly  in  the  course  of  gonor- 
rhoeal  infection  and  is,  of  necessity,  very  grave,  owing  to  the 
danger  to  the  cornea  from  the  compression  of  the  vessels 
which  supply  it.  When  the  effusion  is  very  great  the  swelling 
of  the  ocular  portion  may  extrude  between  the  lids,  and  the 
palpebral  swelling  causes  eversion  of  the  lids,  the  latter  giving 
rise  to  a  spasmodic  action  of  the  orbicularis,  or  blepharospasm, 
which,  by  increasing  the  pressure  upon  the  eyeball,  causes 
increased  danger  to  the  cornea. 

As  the  inflammation  increases  the  secretion  becomes  enor- 
mous, considering  the  small  area  of  the  suppurating  surface. 
The  free  edges  of  the  lids  are  stuck  together  by  the  discharge 
drying  upon  them,  and  their  separation  causes  the  discharge 


212  DISEASES  AND  INJURIES  OF  THE  EYE. 

to  gush  out  with  some  force,  and  oftentimes  with  danger  to 
the  operator.  The  cornea  is  thus  kept  macerating  in  the 
imprisoned  pus.  The  cutaneous  surface  of  the  lids  is  livid, 
transversed  by  enlarged  veins  from  the  passive  congestion. 
Early  in  the  second  stage  it  is  usual  to  notice  unmistakable 
signs  of  pain.  There  may  be  some  marked  febrile  reaction, 
the  child  becomes  restless  and  refuses  the  breast.  If  the 
local  infection  is  slight,  the  child  usually  thrives.  In  the 
majority  of  cases  of  ophthalmia  there  is  no  further  advance  of 
the  disease;  the  inflammation  having  reached  its  height  now 
begins  to  subside,  and  usually  results  in  complete  recovery, 
without  sequelae.  Some  cases,  however,  pass  into  a  chronic 
catarrhal  inflammatory  condition,  and  in  others  the  papillae 
become  hypertrophied  or  true  granulations  result.  If  the 
cases  do  not  end  here,  irreparable  damage  results  from  thft 
third  stage  which  is  entered  upon,  in  which  we  have  involv- 
ment  of  the  cornea  in  the  affection.  "This  complication  is 
more  frequently  the  result  of  gonorrhoeal  infection  or  of  badly 
treated  or  neglected  cases.  The  cornea  may  suffer  only  at 
small  points  or  over  its  whole  surface.  The  corneal  affection 
usually  appears  in  from  eight  to  ten  days  after  the  disease 
has  become  established.  The  corneal  epithelium  is  lost  from 
constant  maceration  in  the  pus,  and  presents  at  first  a  hazy,  or 
milky  appearance,  which  soon  becomes  yellowish  and  finally 
ends  in  complete  suppuration  and,  perhaps,  loss  of  the  lens, 
extrusion  of  the  iris  and  atrophy  of  the  bulb.  If  the  disease 
is  arrested  before  suppuration  the  eye  recovers  with  a  nebu- 
lous cornea,  presenting  much  the  appearance  of  ground  glass; 
this  condition  may  clear  up  very  much  owing  to  the  activity 
of  the  absorbents  in  infancy,  a  result  which  may  be  hastened 
by  the  assistance  of  certain  homoeopathic  remedies. 

In  another  class  of  cases  we  may  have  one  or  more  minute 
grayish  points  of  corneal  infiltration  and  softening  which  give 
rise  to  ulceration  and  perforation.  In  still  others,  the  whole 
cornea  may  slough,  as  the  result  of  the  strangulation  of  the 
vessels  by  the  chemotic  swelling,  so  that  on  the  second  or 
third  day  the  eye  is  entirely  destroyed. 


OPHTHALMIA— NEONATORUM— TREATMENT.  213 

In  the  milder  cases  of  strangulation,  there  may  be  one  or 
more  rapidly  spreading  central  or  marginal  ulcers,  which 
appear  as  if  portions  of  the  cornea  had  been  chipped  out,  with 
clean-cut  edges  and  transparent  bases,  which  are  difficult  to 
detect  unless  viewed  by  oblique  illumination.  These  are 
more  difficult  to  heal  than  the  others;  the  edges  become 
rounded,  blood-vessels  develop  in  them  and  they  rapidly  fill 
up.  As  a  rule,  both  eyes  are  afiected  simultaneously,  or  in 
rapid  succession;  at  times,  one  eye  is  infected  and  the  other 
remains  free. 

In  all  cases  the  eye  should  be  carefully  examined  by  the 
medical  attendant,  and  to  do  this,  the  discharge  should  be 
caiefully  removed  from  the  lid  margins  and  lashes,  and  then 
the  eyelids  separated  by  the  fingers  applied  above  and  below, 
or  if  necessary,  small  retractors  should  be  used;  having  in 
this  manner  obtained  a  view  of  the  whole  of  the  conjunctiva, 
the  cornea  can  also  be  thoroughly  examined.  The  disease 
lasts  from  three  to  six  weeks,  and  much  longer  if  improperly 
treated,  or  neglected. 

Treatment. — The  eyes  should  be  shaded  from  the  light, 
but  it  is  not  necessary  to  confine  the  infant  in  a  darkened 
room,  rather  place  it  in  a  light  and  well-ventilated  apartment. 
The  whole  treatment  hinges  upon  the  frequent  removal  of  the 
discharges,  the  eyes  being  constantly  cleansed  with  scraps  of 
old  linen  or  bits  of  absorbent  cotton,  and  the  further 
cleansing  of  the  eyes  with  solutions  of  chlorine  water  diluted 
one-half,  boracic  acid  (gr.  v.  ad  f^i),  or  arg.  nit.  (gr.  i.  ad 
f3i)  injected  into  the  eye  from  an  eye  dropper,  and  the  use  of 
vaseline  to  the  lid  edges  will  be  sufficient  to  carry  the 
majority  of  cases  to  a  favorable  termination  without  other 
remedies.  The  use  of  cold  compresses  is  not  applicable  to 
such  young  infants,  but  in  case  corneal  afiections  appear, 
frequent  bathing  of  the  eyes  with  warm  water  every  five 
minutes  during  the  day,  and  every  quarter-hour  at  night,  and 
the  use  of  a  solution  of  atropine  (gr.  ^  ad  ffi),  one  drop 
every  three  hours,  will  be  indicated.  The  careful  following 
of  the  directions  for  the  removal  of   the  discharge  and  the 


214 


DISEASES  AND  INJURIES  OF  THE  EYE. 


administration  of  Arg.  nit,  6th  to  30th,  Puis.,  Merc,  or 
Hepar  sulph.  will  be  sufficient  to  bring  the  cases  to  a  favor- 
able termination.  Other  remedies  may  be  useful  and  their 
indications  will  be  found  under  CJonjunctivitis  Purulenta. 

GONORRHEAL     OPHTHALMIA. 

This  variety  of  purulent  conjunctivitis  is  due  to  the  inocu- 
lation of  the  conjunctiva  by  the  secretion  from  an  acute  or 
chronic  inflammation  of  the  urethra,  or  vagina.  The  disease 
sets  in  from  twehe  to  forty-eight  hours  after  the  contagion 
has  been  introduced  into  the  eye,  but  if  the  discharge  has 
become  gleety,  several  days  may  elapse  after  the  eye  has  been 
infected  before  inflammatory  symptoms  appear. 

Symptoms  and  Diagnosis. — The  primary  symptoms  are 
slight  itching  and  redness  of  the  conjunctiva,  followed  almost 
immediately  by  intense  congestion,  with  a  bright,  almost 
scarlet,  chemosis  of  the  conjunctiva.  The  discharge,  which  at 
first  is  serous,  rapidly  becomes  turbid  with  whitish  flakes  of 
pus  and  epithelial  cells.  The  lids  become  swollen  and 
injected.  The  pain  is  often  intense  from  the  pressure  upon 
the  branches  of  the  fifth  nerve  by  the  fibrinous  exudation 
which  infiltrates  the  sub-con junctival  tissue.  This  constitutes 
the  first  or  infiltration  stage  and  the  appearance  of  the  eye  is 
well  portrayed  in  Plate  II,  Fig.  3.  This  stage  reaches  its 
height  in  from  two  to  three  days,  when  the  second  stage,  or 
that  of  purulent  discharge,  occurs.  The  lids  become  more 
swollen,  hard,  tense  and  often  livid,  rendering  it  impossible 
to  open  the  eye,  while  the  upper  lid  hangs  down  over  the 
lower  as  shown  in  Plate  II,  Fig.  4.  The  conjunctiva  becomes 
roughened  and  velvety  from  loss  of  the  epithelium  and  the 
discharge  becomes  thick,  creamy,  yellow,  or,  perhaps,  slightly 
greenish.  The  secretion  is  now  very  profuse  and  collects  in 
drops  on  the  cheek  at  the  edges  of  the  upper  lid  as  shown  in 
Plate  II,  Fig.  4.  The  patient  suff'ers  severely  from  the  pain 
in  the  eye  and  around  the  orbit,  and  complains  of  much  heat 
and  fullness  of  the  lids  and  globe. 


GONORRHCEAL  OPHTHALMIA— TREATMENT.  215 

Prognosis  and  Complications. — The  disease  is  very  rapid 
in  its  progress  and  very  destructive  and  unless  properly 
treated  and  soon  checked,  the  eye  is  lost.  It  usually  reaches 
its  height  in  from  ten  to  twelve  days  while  the  duration  of  the 
disease  may  be  from  four  to  eight  weeks.  The  great  danger 
is  from  corneal  complications  which  arise  from  interference 
with  the  nutrition  of  the  cornea  due  to  the  compression  of  the 
blood-vessels  at  its  margin  by  the  dense  chemosis  which  rises 
above  the  level  of  the  cornea  and  often  overlaps  it.  This 
complication  does  not  usually  occur  until  several  days  after 
the  inception  of  the  disease  and  often  not  until  signs  of 
improvement  in  the  discharge  appear.  As  a  rule,  the  greater 
the  chemosis,  the  greater  the  danger  to  the  cornea.  Fre- 
quently a  narrow  marginal  ulcer  appears  which  tends  to 
extend  insidiously  around  the  periphery  of  the  cornea,  or 
parallel  to  it,  partially  concealed  by  the  overhanging  chemosis ; 
the  central  portion  of  the  cornea  appears  bright  and  clear,  and 
the  danger  may  not  be  realized  until  the  ulceration  has 
extended  over  one-half  or  two-thirds  of  the  circumference, 
when  the  central  portion  suddenly  becomes  opaque  and 
sloughs.  In  other  cases  the  whole  surface  may  become 
grayish  and  infiltrated  from  maceration  in  the  pus  which 
accumulates  and  is  allowed  to  remain  in  the  basin-like  depres- 
sion caused  by  the  chemosis.  At  other  times,  the  morbid 
process  commences  in  a  small  spot  at  the  margin,  or  at  any 
part,  and  rapidly  extends  until  the  whole,  or  the  greater 
portion  of  the  cornea  is  involved.  The  cornea  may  perforate 
and  the  iris  prolapse,  iritis,  or  suppuration  of  the  interior  of 
the  eye  occur;  or,  if  the  cornea  slough,  the  lens,  and  even 
the  vitreous,  may  follow,  and  there  is  a  sudden  relief  of  the 
pain  and  tension,  which  is  regarded  as  a  hopeful  symptom  by 
the  patient,  but  as  a  disastrous  one  by  the  surgeon. 

As  the  disease  is  characterized  by  a  general  hypertrophy  of 
all  portions  of  the  conjunctiva,  it  tends  to  run  into  a  chronic 
stage,  the  papillary  structure  of  the  tarsal  conjunctiva  retain- 
ing this  thickened,  almost  warty,  condition  with  more  or  less 
discharge,  or  finally  trachoma  or  granular  lids  develop. 


216  DISEASES  AND  INJURIES  OF  THE  EYE. 

Treatment. — The  utmost  promptness  and  closest  attention 
are  necessary  to  save  tlie  eye.  In  the  first  stage  the  continual 
application  of  cold  either  in  the  form  of  light  compresses, 
chilled  on  a  block  of  ice  at  the  bedside,  and  changed  eveiy 
minute,  day  and  night;  or  whenever  possible  the  application  of 
ice-bags,  which  are  replaced  as  often  as  the  ice  melts.  No 
other  application  should  be  made  during  this  stage  beyond  a 
solution  of  boracic  acid  gr.  v  ad  f3J,  or  chlorine  water,  diluted 
one  half.  Nitrate  of  silver  should  never  be  used  in  this  stage. 
In  the  second  stage,  the  use  of  nitrate  of  silver  solutions  may 
or  may  not  be  indicated  and,  if  used,  the  behavior  of  the  eye 
after  the  first  application  will  determine  its  future  use.  If 
the  secretion  is  creamy  and  profuse  and  the  conjunctiva 
velvety,  the  application  of  a  solution  of  gr.  xx  ad  f  ^i  which  is 
lightly  applied  to  the  everted  lids  and  quickly  washed  off  by  a 
camel's-hair  brush  with  water  or  milk  may  be  used.  The 
pain  will  be  increased  for  an  hour  after  the  application,  but  is 
relieved  by  the  application  of  the  ice  bags.  The  immediate 
effect  of  the  use  of  the  solution  will  be  to  stop  the  discharge 
for  several  hours.  If  the  discharge  and  swelling  are  lessened 
the  next  day,  it  is  probably  v/ell  indicated,  and  the  application 
may  be  repeated  after  twenty-four  hours.  The  use  of  nitrate 
of  silver  requires  close  observation,  and  if  the  swelling 
becomes  more  tense,  or  if  the  cornea  show  signs  of  infiltration, 
its  use  must  be  abandoned. 

In  the  second  stage,  absolute  cleanliness  is  necessary  and 
the  discharge  must  be  removed  as  often  as  it  accumulates, 
night  and  day,  and  to  do  this  thoroughly  and  well  the  attend- 
ants should  be  provided  with  a  box  of  small  squares  of  old 
muslin,  or  with  absorbent  cotton,  with  which  the  discharge  can 
be  constantly  removed,  and  the  cloths  or  cotton  deposited  in  a 
receptacle  to  be  afterwards  burned,  to  prevent  further  infec- 
tion. To  cleanse  the  eye  properly,  the  lid  should  be  everted, 
and  a  camel's-hair  brush  wet  with  boracic  acid  solution,  or 
chlorine  water,  applied  to  the  conjunctiva  and  particularly  to 
the  folds,  until  all  discharge  is  removed;  this  can  be  rarely 
trusted  to  an  attendant  unless  he  be  a  skilled  nurse,  but  should 


CROUPOUS  CONJUNCTIVITIS.  217 

be  done  at  least  twice  a  day  by  the  medical  attendant,  and  the 
eye  kept  free  of  the  discharge  at  least  every  half  hour  during 
the  interim,  or  oftener,  if  the  discharge  is  very  profuse. 

If  but  one  eye  is  affected,  as  is  usually  the  case,  the  protec- 
tion of  the  other  is  of  the  greatest  importance,  and  for  this 
purpose,  the  sound  eye  should  be  covered  with  a  watch  crystal 
set  in  a  piece  of  rubber  plaster  v/hich  is  affixed  securely  to  the 
bridge  of  the  nose  and  the  eyebrow  and  cheek,  which  allows 
the  patient  to  open  the  eye  and  at  the  same  time  permits  a  full 
inspection  of  its  condition.  It  is  not  well  to  close  the  eye  by 
bandaging,  or  by  the  application  of  plasters,  as  the  discharge 
oftentimes  soaks  through  and  the  eye  becomes  inoculated  and 
the  morbid  process  well  advanced  before  the  condition  is  dis- 
covered. If  the  cornea  becomes  implicated  atropine  (gr.  ii. 
ad  f  si. )  should  be  instilled  every  tw'o  or  three  hours,  and  if 
the  lids  are  very  tense  and  greatly  swollen  so  as  to  cause  pres- 
sure upon  the  cornea,  canthotomy  should  be  performed.  It 
may  be  necessary  to  puncture  the  base  of  the  ulcer  with  a 
cataract  needle,  or  perform  paracentesis  of  the  cornea,  if  per- 
foration is  imminent.  The  cold  applications  which  may  have 
been  used  up  to  this  time,  must  be  stopped  and  warm  com- 
presses applied.  The  use  of  Hepar  sulph.,  Calc.  hyperphos., 
and  Mercurius  wdll  prevent  materially  the  further  destruction 
of  tissue. 

The  indications  for  this  form  of  conjunctivitis  have  already 
been  given  under  Conjunctivitis  Purulenta. 

Croupous  or  Membranous  Conjunctivitis  can  scarcely  be 
termed  a  distinct  form  of  conjunctival  inflammation,  since  it 
may  occur  as  a  complication  of  any  form  of  blennorrhoea  of 
the  conjunctiva,  the  pus  becoming  plastic  or  fibrinous  in  char- 
acter so  that  it  adheres  to  the  membrane,  or  forms  shreds  or 
rolls,  and  is  peeled  off  in  masses,  leaving  the  conjunctiva 
excoriated  and  denuded  of  epithelium  and  often  bleeding.  It 
is  seen  more  frequently  in  infants  and  young  children,  and 
requires  no  special  treatment  beyond  that  indicated  for  the 
relief  of  the  purulent  inflammation  which  accompanies,  or 
rapidly  follows  it.      The  use  of   chlorine  water  seems  to  be 


218  DISEASES  AND  INJURIES  OF  THE  EYE. 

particularly  useful  in  this  condition,  and  the  lids  should  be 
everted  and  the  membrane  thoroughly  removed  by  the  brush 
as  fast  as  it  forms.  The  appearance  of  this  fibrinous  condition 
of  the  pus  always  contra-indicates  the  use  of  nitrate  of  silver 
solutions.  The  frequent  cleansing  often  destroys  this  feature 
of  the  affection,  and  the  membrane  will  not  form  unless  the 
cleansing  process  is  stopped  for  a  few  hours.  This  form  of 
discharge  may  indicate  the  use  of  Acetic  acid,  Apis  mel., 
Hepar,  or  Kali  bich. 

CONJUNCTIVITIS  DIPHTHERITICA. 

DiPHTHEEiTic  Conjunctivitis  is  a  rare  affection  in  this 
country,  but  occurs  epidemically  in  Northern  Europe,  and  is 
not  to  be  confounded  with  the  croupous  form  just  described. 
I  have  seen  but  three  cases  of  this  disease ;  two  resulting  from 
the  extension  of  the  diphtheritic  membrane  from  the  nasal 
cavity  to  the  eye,  and  the  third  the  result  of  direct  contagion 
by  means  of  a  handkerchief,  which  had  been  used  by  a  patient 
suffering  from  faucial  diphtheria. 

Symptoms  and  Course.  —  The  disease  usually  commences 
suddenly,  and  the  eyelids  become  red,  swollen  and  rigid  from 
the  fibrinous  exudation  into  the  subconjunctival  tissue.  Tlie 
chemosis  presents  a  more  grayish  appearance  than  in  the  pur- 
ulent conjunctivitis,  and  is  tense  and  hard.  As  the  disease 
advances,  the  swelling  and  redness  of  the  lids  increases,  and 
the  pain  and  heat  is  very  great.  The  discharge  is  mixed  with 
floculi  of  lymph,  and  is  thin  and  gruel-like ;  this  after  a  few 
days  becomes  purulent  and  the  tissues  of  the  lid  become  more 
soft.  During  the  progress  of  the  disease  fibrinous  exudation 
takes  place  in  the  conjunctiva  of  the  lid,  or  upon  the  globe, 
either  as  small  isolated  gray  patches,  or  as  a  continuous  mem- 
brane which  is  removed  with  much  difficulty,  and  leaves  a 
depression  in  the  conjunctiva.  The  lids  are  stiff  as  well  as 
swollen  and  it  is  almost  impossible  to  evert  them.  The  disease 
may  be  constitutional  as  well  as  local  and  febrile  disturbance 
and  prostration  exist.      The  plastic  stage  is  succeeded  by  a 


CONJUNCTIVITIS  TRACHOMATOSA— TRACHOMA.  219 

stage  of  partial  resolution,  the  membrane  is  thrown  off  and 
leaves  an  ulcerated  condition,  the  discharge  becomes  purulent, 
and  the  eye  may  pass  through  the  various  stages  of  blen- 
norrhoeaic  inflammation.  The  cornea  becomes  implicated  early 
and  the  general  tendency  of  the  disease  is  to  complete 
destruction  of  the  eye.  Even  if  the  vision  is  retained  the 
entropium,  or  ectropium,  of  the  lid  from  cicatrization  and 
contraction  becomes  very  serious. 

Tlie  disease  is  contagious  and,  when  affecting  only  one  eye, 
the  other  must  be  protected  as  in  the  purulent  forms  of 
inflammation. 

Treatment. — The  treatment  is  often  powerless  to  prevent 
the  destruction  of  the  eye.  The  use  of  ice-bags  in  the  early 
stages  of  the  disease  is  of  the  utmost  importance,  and  if  the 
pains  caused  by  their  application  are  very  great,  the  use  of 
chloroform  or  morphine  may  be  necessary  to  allow  of  their 
continuous  application.  Spraying  the  eye  with  cold  chlorine 
water  has  proved  beneficial  when  the  weight  of  the  ice-bag 
could  not  be  tolerated.  Disinfectants  may  be  advantageously 
applied  in  sweet  milk,  as  besides  being  more  soothing  to  the  eye 
than  water,  it  also  gathers  up  the  portions  of  the  membrane  aa 
they  are  thrown  off  AVhen  the  stage  of  purulence  appears,  it 
is  better  to  omit  the  cold  compresses  and  apply  warm  fomen- 
tations to  assist  in  the  elemination  of  the  fibrinous  deposits. 

The  corneal  complications  demand  the  same  treatment  which 
appertains  to  similar  affections  under  ordinary  circumstances. 

The  general  condition  must  be  considered  and  strong  diet  and 
stimulants  will  be  needed  to  sustain  the  strength  of  the  patient. 

For  the  remedial  treatment,  the  use  of  Bell,  and  Bhus  tox. 
will  likely  be  indicated  in  the  early  stage  of  the  disease.  In 
the  purulent  stage  better  results  will  be  obtained  from  Merc, 
cor.  and  Silicia  than  from  Arg.  nii 

CONJUNCTIVITIS  TRACHOMATOSA.— TRACHOMA. 

Granular  Lids  (Plate  II,  Fig.  5)  is  one  of  the  most 
destructive  and  obstinate  affections  that  the  ophthalmic  sur- 


220 


DISEASES  AND  INJURIES  OF  THE  EYE. 


geon  is  called  upon  to  treat  It  depends  upon  a  deposit  of 
lymph  corpuscles  whicli  accumulate  in  small  masses  beneath 
the  epithelium  or  infiltrate  the  tissue  of  the  conjunctiva. 
These  granular  masses  may  exist  for  a  long  time  without 
causing  irritation,  or  may  arise  spontaneously  through  con- 
junctival inflammation,  or  result  from  an  attack  of  purulent 
ophthalmia.  If  the  lids  are  everted,  their  inner  surfaces  are 
seen  studded  with  these  round,  often  yellowish,  or  red,  granu- 
lations which  are  more  abundant  in  the  retro-tarsal  folds. 
(Fig.  87.)  It  is  not  to  be  mistaken  for  the  hypertrophied 
papillae  whicli  are  present  in  all  cases  of  purulent  conjunc- 
tivitis. In  the  latter,  while  the 
conjunctiva  is  thickened,  if  the 
finger  is  applied  it  feels  soft 
and  velvety  to  the  touch,  while 
in  trachoma  the  conjunctiva  is 
smooth,  but  the  granulations 
feel  hard  to  the  finger.  The 
granulations  spread  from  the 
retro-tarsal  folds  to  the  other 
lid  portions  of  the  conjunctiva, 
but  rarely  invade  the  ocular 
portion ;  the  latter,  however,  may  become  hypertrophied  from 
the  constant  irritation  of  the  granulations  upon  the  lid.  As 
the  disease  progresses  the  papillae  and  subconjunctival  tissue 
of  the  lids  become  changed  and  the  inflammatory  process 
causes  a  growth  of  connective  tissue  which  destroys  the  integ- 
rity of  the  conjunctiva,  and  is  afterwards  partly  absorbed,  and 
partly  converted  into  dense  scar  tissue,  which,  as  it  slowly 
contracts,  occasions  changes  in  the  curvature  of  the  tarsus 
and  consequent  distortion  of  the  lid. 

Causes. — The  spontaneous  cases  of  trachoma  seem  to 
result  from  unfavorable  hygienic  conditions,  want  of  cleanli- 
ness and  overcrowding,  and  a  damp  or  vitiated  atmosphere, 
hence  it  occurs  in  military  barracks,  workhouses,  schools, 
asylums  and  public  institutions  which  contain  a  large  number 
of  inmates.  It  is  frequently  the  result  of    neglected  catarrhal 


FIG.  87. 


CONJUNCTIVITIS  TRACHOMATOSA— TRACHOMA.  221 

conjunctivitis,  and  often  follows  purulent  forms  of  conjunctival 
inflammation.  A  low  condition  of  the  health  undoubtedly 
increases  susceptibility  to  it,  and  it  is  common  and  easily  pro- 
duced in  ill-nourished  children  with  bad  hygienic  surround- 
ings. Damp,  and  low  lands  or  flat  countries,  as  our  western 
prairies,  with  severe  winds  during  much  of  the  year,  seem  to 
produce  it  in  patients  whose  general  health  has  been  reduced 
by  exposure,  and  want  of  proper  food,  or  clothing.  It  is  a 
very  common  disease  among  the  Jewish  and  Irish  races,  while 
the  Negroes  seem  to  enjoy  immunity  from  it.  When  accom- 
panied by  discharge  the  disease  is  contagious,  and  is  spread 
very  commonly  by  the  use  of  towels  and  water  which  have 
been  infected  by  the  discharge.  The  sources  of  contagion, 
however,  are  endless  and  the  disease  is  often  disseminated  in 
hospitals,  barracks,  etc,  through  the  confined  atmosphere. 

Symptoms  and  Diagnosis. — If  the  disease  arises  spontane- 
ously, or  is  idiopathic,  and  takes  a  chronic  course  it  occasions 
but  little  discomfort  beyond  that  which  occurs  in  catarrhal 
forms  of  conjunctival  inflammation.  During  the  first  stage  a 
mucous,  or  in  severe  cases  a  muco-purulent,  discharge  is 
present  which  is  not  profuse,  and  only  disturbs  the  patient  by 
clouding  the  vision  by  covering  the  cornea,  or  evaporating 
during  the  night  and  so  gluing  the  lids  together,  or  the  lids 
become  thickened  and  heavy  so  that  the  levator  is  no  longer 
able  to  raise  them  and  a  partial  ptosis  occurs.  This  condition 
may  last  for  months  or  years  without  causing  sufficient  trouble 
to  the  patient  to  necessitate  his  seeking  advice.  If,  however, 
he  is  exposed  to  cold,  or  the  weather  is  raw  and  damp  he  may 
have  an  acute  inflammatory  condition  set  up,  and  the  conjunc- 
tiva becomes  very  red,  thickened,  chemotic  and  perhaps  the 
lids  oedematous,  and  a  profuse  muco-purulent  discharge  fol- 
lows, the  condition  becoming  one  of  acute  irachoma  or  acide 
granulations,  and  the  cornea  becomes  implicated.  This  stage, 
however,  soon  passes  away  and  the  chronic  condition  is 
resumed. 

Acute  trachoma  is  a  rare  condition,  but  does  occur;  the 
soft  smooth  conjunctiva  becomes  rapidly  transformed  into  a 


222  DISEASES  AND  INJURIES  OF  THE  EYE. 

hard  nodular  tissue  with  few  blood-vessels  and  the  secretion  is 
much  increased  and  half  puruleni 

The  second  stage  is  characterized  by  the  formation  of  cica- 
tricial tissue,  and  the  granular  bodies  either  disappear  and 
leave  tendinous  bands  running  through  the  conjunctiva,  or 
there  is  a  fatty  degeneration  of  the  deposits. 

During  the  progress  of  the  disease  acute  exacerbations  from 
cold,  exposure,  or  irritation,  are  the  rule,  and  with  each  occur- 
rence there  is  a  general  aggravation  of  the  whole  condition, 
and  increased  tendency  to  corneal  or  other  complications  with 
increased  discharge.  The  results  and  complications  of  tra- 
choma are  numerous  and  severe;  they  consist  of  haziness, 
opacity,  ulceration  and  vascularity  of  the  cornea,  trichiasis, 
distichiasis,  and  entropium,  and  destruction  and  atrophy  of  the 
conjunctiva.  During  the  course  of  trachoma  the  cornea  almost 
invariably  suffers  from  friction  of  the  granulations  of  the 
upper  lid;  or  where  there  is  much  scar  tissue  in  the  conjunc- 
tiva, the  cornea  becomes  hazy  fi'om  destruction  of  the  epithelial 
layer;  or  corneal  ulcers  may  occur  and  result  in  perforation 
or  iritis.  The  most  common  complication  is  a  vascular 
haziness  which  commences  at  the  upper  edge  of  the  cornea 
and  spreads  until  the  upper  half,  or  often  the  whole  of  it, 
becomes  covered  with  an  opaque  red  coating.  This  consists 
of  the  development  of  a  layer  of  new  tissue  with  large  blood- 
vessels just  beneath  the  epithelial  layer  of  the  cornea,  and 
known  as  pannus,  or  pannus  crassus.  This  condition  may  also 
arise  in  the  later  stages  of  the  disease  from  inversion  of  the 
cilia.  As  the  granulations  subside  and  the  irritation  is 
removed,  the  pannus  may  disappear  entirely,  if  Bowman's 
membrane  has  not  been  implicated,  and  the  cornea  becomes 
clear  again.  In  the  majority  of  cases  a  haziness,  or  if  there 
has  been  ulceration,  an  opacity  remains,  or  there  may  be  fatty 
degeneration  of  the  epithelial  layer,  and  a  thin  whitish  film 
will  cover  a  portion  or  the  whole  of  the  cornea,  which  appears 
hazy  and  dry,  the  condition  known  as  pannus  sicca.  In  the 
later  stages  of  the  disease,  as  the  inflammation  subsides,  the 
lymph  corpuscles  are  replaced  by  cicatricial  tissue  which  may 


CONJUNCTIVITIS  TRACHOMATOSA— TRACHOMA.  223 

seam  the  inuer  surface  of  tlie  lid  in  all  directions,  and  in 
shrinking  aflfect  the  deeper  tissues,  and  this  leads  to  distortion 
of  the  edges  of  the  lid,  and  misdirection  and  changes  in  the 
eyelashes  so  that  some,  or  all  of  them,  are  directed  more  or 
less  inward  and  cause  trichiasis  and  distichiasis,  which  also 
result  in  pannus.  Again  this  contracting  tissue  increases  the 
convexity  and  apparently  lessens  the  size  of  the  tarsus  of  the 
lids  and  causes  entropium.  When  the  disease  has  advanced 
to  its  last  stage  the  conjunctiva  is  found  atrophied,  the  retro- 
tarsal  folds  have  disappeared  and  perhaps  have  been  replaced 
by  dense  fibres  of  scar  tissue,  and  the  glands  which  moisten 
the  conjunctive  have  become  involved  in  the  destructive  pro- 
cess and  the  conjunctiva  becomes  dry  as  in  the  condition 
known  as  xerosis. 

Amyloid  degeneration  of  the  conjunctiva  is  a  very  rare  dis- 
ease which  occurs  as  a  sequela  of  trachoma.  It  may  occur  in 
the  folds,  or,  as  in  the  only  case  I  have  observed,  upon  the 
conjunctiva  bulbi  near  the  upper  fold,  and  appears  as  a  thick 
jelly-like  mass,  yellowish  in  color  which  may  be  of  sufficient 
size  to  extrude  between  the  folds,  and  requires  incision  for  its 
relief  or  removal. 

Tkeatment. — Granular  lids,  if  presenting  an  acute  inflam- 
matory condition,  require  similar  local  and  internal  treatment 
to  that  recommended  for  purulent  conjunctivitis.  In  the 
chronic  form  the  inflammation  is  more  asthenic  in  character 
and  treatment  must  be  adopted  to  allay  the  inflammation  and 
also  produce  absorption  of  the  granulations. 

In  all  cases  the  hygienic  surroundings,  cleanliness,  pure  air, 
and  a  generous  diet,  together  vnih.  measures  suitable  to 
improve  the  low  debilitated  condition  of  the  patient  which  is 
generally  present  in  this  affection  must  receive  attention.  The 
avoidance  of  exposure  to  damp  and  cold,  and  bright  lights  and 
irritants  should  be  insisted  upon.  The  utmost  cleanliness  of 
both  the  eyes  and  the  person  are  necessary,  and  care  must  be 
taken  to  prevent  the  spread  of  the  contagion  to  others;  where 
cases  occur  in  hospitals  or  public  institutions  they  should  be 
isolated  in    separate  rooms,    and    provided   with   towels    and 


224  DISEASES  AND  INJURIES  OF  THE  EYE. 

basins  for  each  individual.  If  there  is  an  endemic  tendency, 
the  other  inmates  should  be  examined  every  few  days,  or 
weeks,  as  the  disease  may  appear,  particularly  in  children, 
without  much  external  manifestation. 

The  direct  treatment  of  the  disease  consists  in  the  local 
application  of  such  irritating  remedies  as  will  stimulate  the 
action  of  the  absorbents  of  the  conjunctiva  and  thus  cause  a 
removal  of  the  deposits  of  lymph  corpuscles.  The  agents 
which  have  been  recommended  and  used  for  this  purpose  are 
almost  numberless.  In  considering  the  applicability  of  caus- 
tics in  this  disease,  it  should  be  borne  in  mind  that  the 
conjunctiva  does  not  present  an  ulcerating  surface  like  a 
wound,  and  the  granulations  of  trachoma  are  not  similar  to 
those  of  a  suppurating  surface,  but  penetrate  deeply  into  the 
conjunctival  tissue,  and  do  not  admit  of  destruction  by  caustic 
application  without  an  accompanying  loss  of  tissue,  which 
renders  the  resulting  condition  of  the  eye  more  serious  in 
many  cases,  than  it  would  have  been  had  the  disease  been 
allowed  to  run  its  course  without  treatment.  There  is  no 
single  agent  which  will  be  universally  suitable,  and  individual 
cases  often  require  the  rotation  of  local  applications.  As  a 
rule  it  may  be  stated  that  the  more  irritable  the  eye  is,  the  more 
mild  the  application  should  be,  so  as  not  to  excite  increased 
inflammatory  action  which  too  often  results  in  increased 
deposits  of  the  lymph  cells. 

The  most  commonly  recommended  application  in  these 
cases  is  the  sulphate  of  copper  crystal  which  is  lightly  applied 
to  the  conjunctiva  daily  or  tri-weekly.  Again,  nitrate  of 
silver  either  pure  or  combined  with  nitrate  of  potash  in  the 
mitigated  stick  is  much  lauded  by  some  surgeons ;  where  %l 
find  it  advisable  to  use  copper  I  prefer  the  aluminate,  but  this 
is  also  too  severe  for  the  majority  of  cases.  A  careful  obser- 
vation in  my  own  practice  of  the  effects  produced  by  these 
agents  leads  me  to  believe  that  they  more  frequently  injure 
rather  than  benefit.  The  topical  application  of  cald  by  means 
of  ice-bags,  in  both  the  acute  exacerbations  and  the  chronic 
conditions,  for  several  hours  each  day  and  the  use  of  tannic 


CONJUNCTIVITIS  TRACHOMATOSA— TRACHOMA.  225 

acid  and  glycerine  (gr.  xv  ad  fsi),  carbolic  acid  and  glycerine 
(gtt.  ii-iii  ad  fsi),  or  a  solution  of  nitrate  of  silver  (gr.  v  to  x 
ad  f3i)  applied  to  the  everted  lids  by  means  of  a  camel's-liair 
brush,  once  daily,  accomplish  all  that  can  be  done  towards 
hastening  the  absorption  of  the  deposits.  Occasionally  the 
instillation  of  the  watery  solutions  of  tincture  of  Aconite, 
Hydrastis,  or  Sanguinaria,  (gtt.  x  to  xv  ad  fsi)  seems  cura- 
tive. Recently  good  results  have  been  attained  by  the  use  of 
a  decoction  of  the  seeds  of  the  abrus  prcecaiorius,  or  jequiriiy. 
A  concentrated  solution  is  dropped  into  the  eyes  once  a  day 
for  three  successive  days.  The  jequirify  produces  several 
hours  after  its  introduction  an  intense  and  painful  inflam- 
mation, when  a  strong  solution  is  used.  If  a  milder  solution 
is  used  there  may  be  only  heaviness  of  the  eyelids,  burning, 
lachrymation,  and  injection  of  the  conjunctiva  or  headache. 
To  derive  any  satisfactory  benefit  from  its  use,  a  sufficiently 
strong  decoction  must  be  employed  to  excite  a  purulent 
conjunctivitis,  similar  to  that  from  inoculation,  but  which 
is  more  readily  controlled  than  the  latter.  The  application 
requires  the  greatest  care  and  circumspection  and  is  a 
remedy  which  can  only  be  applied  by  the  ophthalmic 
surgeon  with  any  degree  of  safety.  Much  more  reliance 
should  be  placed  upon  the  administration  of  remedies, 
particularly  for  the  acute  attacks,  and  also  in  those  cases 
exhibiting  that  irritable  condition  which  does  not  tolerate  the 
use  of  local  adjuvants.  The  remedies  most  frequently  indi- 
cated are  Aconite,  Euphras.,  Merc,  bin.,  Merc,  prot,  Rhus, 
Calc.  hyperphos.,  Ars.,  and  Sulphur. 

Pannus  requires  no  special  treatment  as  it  generally  yields 
to  the  treatment  of  the  granulations.  If  there  is  much  pain 
with  the  condition  atropine  should  be  used.  It  is  often  an 
indication  for  the  use  of  Merc,  prot.,  both  internally  and  exter- 
nally, in  the  latter  case  combined  with  vaseline  (gr,  ii  ad  3i), 
or  Aurum  met.  may  be  used  in  some  cases  with  great  benefit. 
When  the  pannus  remains  after  the  granulations  have  disap- 
peared, the  operaiion  of  periotomij,  which  consists  of  the 
removal  of  a  circular  ring  of  conjunctiva  4  mm.  broad  from 

15 


226  DISEASES  AND  INJURIES  OF  THE  EYE. 

the  globe  at  the  junction  of  the  cornea  and  sclera,  will  cause  a 
disappearance  of  the  blood-vessels  from  the  cornea.  In  cases 
of  inveterate  pannus  the  inoculation  of  the  conjunctiva  with 
pus  from  a  purulent  conjunctivitis  has  been  recommendetl, 
but  it  is  of  very  doubtful  utility  as  well  as  dangerous. 
Ulcerations  of  the  cornea  require  prompt  attention  to  prevent 
perforation  and  may  require  the  use  of  atropine  or  oserine 
together  with  the  use  of  the  bandage,  and  Merc.  nit.  internally, 
and  externally  a  solution  of  the  Ix  gr.v  ad  f^i  will  give  good 
results. 

If  trichiasis  or  entropium  result  a  suitable  operation  is  to  be 
performed  for  their  relief. 

For  the  xerosis  or  dry  condition  of  the  cornea  which  results 
in  some  cases  from  the  almost  complete  atrophy  of  the  conjunc- 
tiva nothing  can  be  done  beyond  the  frequent  application  to 
the  eye  of  some  oily  substance  as  castor  oil,  olive  oil  or 
vaseline. 

Follicular  Conjunctivitis  is  an  affection  which  is  fre- 
quently classed  with  trachoma,  but  it  would  seem  to  be  a 
distinct  disease.  It  is  characterized  by  the  appearance  of 
numerous  hemispherical  translucent  vesicles  which  occur  in 
the  folds  of  transmission  of  the  lower  lid,  rarely  upon  the 
tarsus,  and,  in  less  number,  upon  the  conjunctiva  of  the  upper 
lid  where  they  are  also  more  numerous  at  the  folds.  Patho- 
logically, they  appear  to  be  swelling  of  the  lymphatic  follicles 
of  the  conjunctiva,  and  not  simply  deposits  of  lymph  cells 
as  in  trachoma,  although  the  two  conditions  are  often  present 
in  the  latter  disease. 

Unfavorable  hygienic  conditions  and  defective  nutrition  seem 
to  be  the  most  frequent  cause  of  these  follicular  swellings 
which  occur  commonly  in  children  and  young  people.  There 
is  slight,  if  any,  discharge,  and  the  patients  may  complain  of 
no  symptoms  beyond  those  of  simple  hypersemia  of  the  con- 
junctiva ,  the  condition  may  be  present  for  a  long  time  without 
occasioning  any  trouble  and  does  not  produce  pannus,  but 
seems  to  cause  a  predisposition  to  other  troubles  of  the  con- 
junctiva on  slight  irritation. 


CONJUNCTIVITIS  PHLYCTENULARIS.  227 

The  treatment  consists  in  the  use  of  Nat  mur.,  or  Euta 
grav.,  and  a  colljrium  of  boracic  acid. 

CONJUNCTIVITIS  PHLYCTENULARIS. 

Phlyctenular  or  Pustular  Conjunctivitis  (Plate  II,  Fig.  2) 
is  a  recurrent  form  of  inflammation,  characterized  by  the 
appearance  of  one  or  more  vesicles  or  papules  upon  the  ocular 
conjunctiva,  supposedly  around  the  terminal  filaments  of  the 
branches  of  the  fifth  nerve,  and  often  occurring  near  the  cornea. 
Each  papule  or  phlyctenule  forms  a  small  patch  of  localized 
congestion  towards  which  converge  a  leash  of  vessels  which 
can  frequently  be  traced  back  to  the  folds  of  the  conjunctiva. 
These  phlyctenules  may  present  a  semi-transparent  or  yellowish 
elevation  or  be  more  flat,  large,  and  give  the  appearance  of 
gelatinous  infiltration  at  that  point.  There  may  be  one  or 
many  scattered  over  the  ocular  conjunctiva  or  aggregated  at 
the  corneal  margin,  or  they  may  encircle  it  and  appear  upon 
the  cornea  also.  In  a  few  days  these  vesicles  which  form  the 
summit  of  the  phlyctenule  rupture,  and  leave  a  shallow  ulcer 
with  a  yellowish  base  which  heals  in  a  few  days.  In  some 
cases  small  points  of  congestion  only,  appear  and  after  a  short 
time  subside  without  the  formation  of  a  vesicle.  The  pain  is 
usually  very  slight,  the  photophobia  or  dread  of  light  variable, 
and  in  some  cases  very  slight,  in  others,  intense  and  accom- 
panied by  severe  blepharospasm.  The  secretion  is  commonly 
scant  and  mucoid  in  character. 

The  disease  shows  a  great  tendency  to  recur  and  the  phlyc- 
tenules appear  in  successive  crops  after  the  lapse  of  weeks  or 
months.  They  are  very  prone  to  appear  in  the  winter  and 
spring.  Children  have  a  peculiar  liability  to  the  disease,  as  it 
is  only  rarely  seen  in  adults,  and  may  be  considered  as  indica- 
tive of  some  derangement  of  the  general  health.  It  is  common 
to  delicate  and  ill-nourished  children,  particularly  those  w^ho 
live  upon  an  almost  exclusively  starch  diet,  or  use  tea  and 
coffee. 

Treatment. — The  treatment  consists  in  the  improvement  of 


228  DISEASES  AND  INJURIES  OF  THE  EYE. 

the  general  tone  of  the  patient,  and  the  restriction  of  such 
nerve  stimulants  as  tea  and  coffee.  The  patient  should  be 
urged  to  live  upon  a  more  mixed  diet,  as  many  cases  cannot 
be  cured  until  a  moderate  amount  of  meat  enters  into  the 
daily  nourishment.  External  applications  are  rarely  necessary 
as  the  cure  is  much  more  rapid  and  permanent  by  the  use  of 
internal  remedies  than  with  topical  applications.  Of  the  latter, 
those  which  are  generally  recommended  are  the  yellow  oint- 
ment, a  small  bit  of  which  is  introduced  between  the  lids  and 
allowed  to  melt  upon  the  conjunctiva,  or  calomel  dusted  into 
the  eye,  or  solutions  of  mere.  nit.  dropped  into  it. 

REMEDIES. 

Sulphur. — Very  frequently  indicated  in  cases  occurring  in 
scrofulous  children.  Its  sphere  of  action  is  very  wide  and 
suits  a  great  variety  of  cases  of  pustulous  inflammation  of  the 
conjunctiva,  and  is  particularly  indicated  when  there  are  sharp, 
darting  lancinating  pains,  or  as  if  pins  and  needles  were  stick- 
ing in  the  eye  during  the  day,  or  the  pains  aggravated  after 
midnight.  There  may  also  be  itching,  often  a  thickened 
condition  of  the  lid  and  much  rubbing  of  the  eyes.  The 
photophobia  is  variable  and  may  be  quite  marked  in  the  morn- 
ing. The  lachrymation  is  usually  profuse  and  the  lids  gener- 
ally stick  together  on  wakening.  There  is  often  an  eczematoua 
condition  of  the  lids,  face  and  head,  and  a  general  aggravation 
from  the  application  of  cold  water,  or  from  bathing   the  eyes. 

Pulsatilla. — The  phlyctenules  are  more  frequently  small 
but  often  numerous;  the  photophobia  or  pain  are  commonly 
slight  and  the  redness  variable.  The  lachrymation  and  dis- 
charge are  moderate  and  bland,  although  it  is  not  contra- 
indicated  if  the  secretions  are  profuse.  Particularly  suitable 
to  the  blonde  women  and  children  upon  whom  Pulsatilla  seems 
to  have  so  good  an  action. 

Mercurius  sol. — A  valuable  remedy  in  many  cases  of  phlyc- 
tenular inflammation  in  strumous  or  syphilitic  children.  There 
is   usually  marked   redness   of   the    conjunctiva,  and   violent 


CONJUNCTIVITIS  PHLYCTENULARIS— REMEDIES.  229 

photophobia,  so  that  all  light  must  be  excluded,  and  the  dis- 
charge usually  thin  and  acrid.  The  pains  are  severe  and 
neuralgic  in  character,  affecting  the  temporal  side  of  the  head 
and  face.  They  are  variously  described  as  burning,  sharp, 
tearing,  and  lancinating,  and  aggravated  in  the  evening  and 
from  exposure  of  the  eyes  to  artificial  light,  by  heat  and  damp 
weather,  while  there  is  a  temporary  relief  from  application  of 
cold  water  to  the  eyes.  The  lids  are  often  thick  and  swollen 
and  spasmodically  closed  and  excoriated  by  the  discharge. 

Merc.  cor. — Indicated  in  the  aggfravated  form  of  inflamma- 
tion  occurring  in  scrofulous  children.  The  symptoms  are 
much  more  marked  tlian  in  the  other  preparations  of  Mercury, 
the  pains,  photophobia,  lachrymation,  all  being  aggravated; 
the  nostrils  are  often  excoriated  by  the  acrid  discharge  from 
the  eye  passing  down  into  the  nose. 

Mercurius  diilcis. — Although  calomel  is  used  very  exten- 
sively by  the  old  school  in  scrofulous  ophthalmia  it  is  but 
rarely  applicable  to  phlyctenular  inflammation;  some  cases 
occurring  in  pale,  flabby  subjects,  with  excoriation  of  the  nose, 
and  swelling  of  the  upper  lip,  have  been  benefited. 

Mercurius  mi. — This  remedy,  recommended  by  Dr.  Liebold, 
has  been  used  by  him  with  remarkable  success  in  a  great 
variety  of  cases  of  phlyctenular  inflammation.  It  seems  to 
suit  severe  as  well  as  mild  affections,  acute  or  chronic,  with,  or 
without  much  photophobia,  and  in  some  cases  presenting 
severe  pain,  in  others  where  the  pain  is  absent.  It  may  be 
used  both  internally  and  externally.  If  externally,  ten  grains 
of  the  first  decimal  trituration  is  to  be  dissolved  in  two  drams 
of  water  and  applied  two  or  three  times  a  day. 

Graphites. — This  is  one  of  the  most  valuable  remedies  we 
have  for  all  forms  of  phlyctenular  inflammation.  It  is  useful 
in  both  the  acute  and  chronic  forms,  particularly  in  cases 
where  there  is  a  marked  tendency  toward  recurrence.  It  is 
specially  indicated  in  scrofulous  cases,  or  with  exanthem- 
atous  eruptions  about  the  head  or  behind  the  ears,  particularly 
■where  the  eruptions  are  glutinous,  fissured  and  bleed  easily. 
The  photophobia  is  usually  very  marked,  and  the  lachryma- 


230  DISEASES  AND  INJURIES  OF  THE  EYE. 

tion  profuse,  although  in  some  cases  nearly  or  entirely  absent. 
There  is  generally  a  greater  aggravation  from  sunlight  than 
gaslight,  and  in  the  morning,  so  that  often  the  child  cannot 
open  the  eyes  before  nine  or  ten  o'clock.  The  conjunctiva  is 
frequently  very  red,  and  the  discharges  are  muco-purulent, 
constant,  thin  and  excoriating.  The  pains  are  variable  and 
not  characteristic;  the  lids  are  sore,  red  and  agglutinated  in 
the  morning,  or  else  covered  with  dry  crusts,  while  the  exter- 
nal canthi  are  fissured  and  bleed  easily  upon  opening  the  eye. 
There  may  be  also  an  acrid  discharge  from  the  nose  accom- 
panying the  eye  affection. 

Calc.  carh. — Phlyctenules  appearing  in  fat,  unhealthy  chil- 
dren, with  pale  flabby  skin  and  enlarged  glands.  The  photo- 
phobia is  often  excessive,  and  the  lachrymation  very  great  and 
often  acrid.  The  redness  and  pains  (sticking  in  character) 
are  variable  and  the  lids  perhaps  swollen  and  glued  together 
in  the  morning. 

Cede,  sulpli. — Will  prove  exceedingly  valuable  in  many 
cases  when  the  general  symptoms  of  calcarea  are  present  with 
enlargement  of  the  cervical  glands.  The  lower  attenuations 
should  be  used. 

Hepar  sulph.  —  Is  adapted  to  phlyctenular  inflammation 
occurring  after  measles,  or  in  strumous  children,  when  there  is 
intense  photophobia,  lachrymation,  an  injection  of  the  con- 
junctiva, with  swelling  of  the  lids,  sensitiveness  to  touch  and 
a  desire  to  have  them  covered,  and  when  the  external  canthi 
bleed  easily  on  opening  them. 

Arsenicum. — Cases  occurring  in  thin,  ill-nourished  children, 
without  marked  inflammatory  symptoms.  There  is  usually 
intense  photophobia,  and  profuse,  acrid  lachrymation.  The 
phlyctenules  tend  to  form  ulcers  which  extend  superficially 
and  take  on  an  indolent  character. 

Mhiis  iox. — When  there  is  excessive  photophobia,  lachryma- 
tion and  spasmodic  closure  of  the  lids.  There  is  generally  a 
vesicular  or  pustular  eruption  upon  the  eyelids  or  face. 

Antim.  tart,  Ipec,  Kali  bi.,  Mez..  Crot.  tig ,  Euphrasia, 
Sepia,  and  Baryta,  are  also  serviceable  in  phlyctenular  con- 
junctivitis and  will  give  prompt  results  when  indicated. 


INFLAMMATION  OF  THE  CARUNCLE— PTERYGIUM.  231 

Inflammation  of  the  Caruncle  occurs  in  rare  instances 
and  is  characterized  by  an  enlargement  of  the  gland,  and  in 
one  case  I  liave  observed  suppuration.  The  caruncle  is 
commonly  involved  in  conjunctivitis,  or  inflammation  of  the 
semilunar  folds,  which  occurs  in  some  instances  from  acute 
exacerbations  of  chronic  nasal  catarrh. 

Arg.  nit,  internally,  with  a  mild  astringent  lotion,  are  usually 
sufficient  to  relieve  the  condition  and  prevent  the  extension  of 
the  inflammation  to  other  portions  of  the  conjunctiva.  The 
caruncle  is  sometimes  the  seat  of  hypertrophy,  becoming  so 
large  as  to  extrude  between  the  lids ;  the  use  of  tannic  acid  and 
glycerine  locally  and  Calc.  iod.  internally  caused  the  enlarge- 
ment to  subside  in  one  case.  The  hypertrophy  should  not  be 
excised,  as  the  puncta  might  be  displaced  by  the  subsequent 
atropliy. 

Calcareous  masses  sometimes  form  in  one  of  the  numerous 
meibomian  glands  which  compose  the  caruncle  and  an  incision 
and  removal  of  the  accumulation  is  all  that  is  necessary. 

Polypi  sometimes  spring  from  the  caruncle  and  may  be  cut 
off  with  a  pair  of  scissors;  the  hemorrhage,  which  may  be 
profuse,  is  controlled  by  the  pressure  of  a  wad  of  absorbent 
cotton  upon  it  for  a  few  moments. 

Pterygium  (Plate  II,  Fig,  6)  consists  of  an  hypertrophy  of 
a  portion  of  the  ocular  conjunctiva  and  subconjunctival  tissue, 
which  is  often  very  vascular,  and  has  usually  a  triangular 
shape,  the  base  of  the  triangle  being  towards  the  cauthus,  or 
retro- tarsal  fold,  and  the  apex  extending  upon  the  cornea.  Its 
most  frequent  seat  is  at  the  inner  canthus,  but  it  may  appear 
at  the  outer,  or  above  or  below  the  cornea ;  as  it  increases  in 
size  it  extends  more  and  more  over  the  cornea.  Its  gi'owth  is 
slow,  but  it  is  often  subject  to  attacks  of  inflammation  which 
result  in  its  more  rapid  advancement. 

Causes. — It  is  occasioned  by  the  irritation  of  dust  or  wind 
in  adults  who  are  exposed  to  the  changes  of  the  weather.  In 
some  cases  it  is  caused  by  the  overlapping  and  adhesion  of  the 
conjunctiva  to  an  ulceration  of  the  cornea  near  its  margin. 
The  dragging  of  this  portion  of  the  conjunctiva  on  motion  of 
the  eye  results  in  a  thickening  of  the  tissue. 


232  DISEASES  AND  INJURIES  OF  THE  EYE. 

Treatment— Zincwoa.,  Sulpli.,  Calc.  carb.,  Cliimaphila,  and 
Hhatania,  are  reported  as  having  cured  some  cases,  but  a 
thorough  trial  has  failed  to  find  absorption  follo\r  their  admin- 
istration in  marked  cases.  AVhere  the  growth  has  encroached 
much  upon  the  cornea  it  is  better  to  remove  it  by  an  operation. 
Tor  this  purpose  the  procedure  of  Arlt  answers  well.  The 
pterygium  is  seized  at  the  apex  by  a  pair  of  fixation  forceps 
and  the  portion  overlying  the  cornea  carefully  dissected  oflf 
with  a  Beers'  or  bent  knife,  then  with  a  pair  of  sharp-pointed 
scissors  the  growth  is  separated  from  the  conjunctiva  on  each 
side  and  cleanly  dissected  up  from  the  sclera  for  a  distance  of 
nearly  half  an  inch,  the  conjunctiva  on  the  sides  of  the  wound 
being  loosened  from  the  globe  sufficiently  to  enable  the  edges 
to  be  brought  well  together  and  united  by  one  or  two  sutures, 
and  the  pterygium  then  left  to  atrophy. 

If  the  mass  is  very  thick  or  broad  it  is  better  to  dissect  it 
■up  to  the  inner  canthus,  excise  it,  and  bring  the  conjunctiva 
together  as  before.  If  the  growth  is  narrow,  good  results  are 
obtained  by  dissecting  it  up  as  before,  and  then  making  a 
longitudinal  incision  in  the  conjunctiva  below  the  cornea  and 
turning  the  pterygium  dowil  and  stitching  it  there,  where  it 
soon  atrophies.  The  conjunctiva  is  then  brought  together 
over  the  space  from  which  it  was  dissected,  the  eye  bandaged, 
or  cold  water  compresses  applied,  and  the  sutures  allowed  to 
remain  for  three  or  four  days.  If  the  growth  is  very  large 
there  is  danger  of  eversion  of  the  lid  from  its  transplantation 
in  this  manner. 

The  operation  for  ligation  is  no  longer  practiced,  as  it  is 
very  painful  and  comparatively  useless. 

Symblepharon,  or  union  of  the  conjunctiva  of  the  lids  to 
that  of  the  globe,  (Plate  II,  'Fig.  5,)  is  the  result  of  burns  or 
other  injuries  which  destroy  portions  of  the  conjunctiva,  so 
that  adhesion  takes  place  by  cicatricial  bands  notwithstanding 
the  efforts  made  to  prevent  such  occurrences  by  the  methods 
already  described  in  discussing  injuries  of  the  conjunctiva. 
If  the  extent  of  symblepharon  is  great,  the  movements  of  the 
eye  are  interfered  Avith,  and  it  occasions  much  irritation  which 


SYMBLEPHARON—TREA  TMENT. 


233 


may  destroy  tlie  vision  or  excite  sympathetic,  inflammation  of 
tlie  other  eye. 

Treatment. — If  the  adhesions  are  small,  they  may  be 
divided  with  the  scissors  or  knife,  and  re-union  prevented  by 
the  instillation  of  castor  oil  or  vaseline,  and  the  frequent 
drawing  of  the  lid  away  from  the  ball  until  the  wound  is 
healed;  or  the  conjunctiva  of  the  bulb  may  be  loosened  around 
the  cicatrix  and  brought  together,  so  as  to  cover  the  raw 
surface.  For  more  extensive  cases,  the  operation  devised  by 
Teale  will  be  found  useful.     An  incision  is  made  as  in  Yis. 


FIG.  88. 


FIG.  89. 


FIG.  90. 


88  in  a  curved  line  corresponding  to  the  margin  of  the  par- 
tially covered  eyeball,  while  the  portion  A  on  the  cornea  (Fig. 
89)  is  allowed  to  remain;  two  conjunctival  flaps  B  and  C  are 
then  made  of  sufficient  width  and  breadth  to  cover  the  raw 
surface  at  D,  and  gently  turned  down  and  secured  in  position 
by  fine  sutures,  and  the  gap  left  by  the  transplanted  flaps  also 
closed  by  sutures,  as  in  Fig.  90.  Dry  dressings  are  then 
applied.  In  some  cases  the  grafting  of  a  portion  of  the  con- 
junctiva of  a  rabbit  is  successful. 

Tumors  of  the  Conjunctiva  rarely  occur  except  by  exten- 
sion from  adjacent  tissue. 

Polypus  arises  occasionally  at  the  inner  canthus  or  from 
the  stump  of  the  muscle  after  tenotomy.  Calc.  carb.  inter- 
nally is  reported  as  having  cured  polypus  of  the  conjunctiva. 
They  are  generally  small  in  size  and  pedicellated.  They  are 
readily  and  easily  removed  by  snipping  them  off  with  the 
scissors. 

Pinguecula  is  a  small,  yellowish,  elevation,  occurring  in 
adult  life  on  the  ocular  conjunctiva,  between  the  cornea  and 
the  inner  canthus,  and  presents  the  appearance  of  an  aggrega- 


234  DISEASES  AND  INJURIES  OF  THE  EYE. 

tion  of  fat  cells,  but  really  consists  of  liypertrophied  connec- 
tive tissue,  elastic  fibres  and  epithelial  cells.  It  is  innocuous 
and  can  be  removed,  if  desired,  by  excising  with  a  pair  of 
scissors. 

Warts  and  Dermoid  Growths  sometimes  found  upon  the 
conjunctiva  are  usually  congenital,  and  should  be  removed. 

Pigment  Deposits  sometimes  occur  and  may  be  associated 
with  malignant  growths.  One  case,  I  have  seen,  was  cleared 
up  by  Sepia. 

Cysts  of  the  conjunctiva  appear  with  moderate  frequency, 
and  usually  after  trachoma.  They  are  translucent  and  gen- 
erally require  only  incision  of  the  sac  for  removal  of  the 
contents. 

Epithelioma  and  Sarcoma  are  very  rare  except  by  exten- 
sion from  the  globe  or  lids.  When  occurring  independently, 
they  should  be  removed.  Ars.  and  Lapis  alb.  have  been 
reported  as  producing  improvement. 

Lupus  and  Syphilitic  Ulceration  are  also  rare  except 
by  extension,  and  require  no  different  treatment  from  that 
already  considered  in  similar  affections  of  the  lid. 

Encanthus  is  a  congenital  hypertrophy  of  the  semi-lunar 
folds  and  may  be  associated  with  epicanthus. 


CHAPTEK    XI.  * 
DISEASES  OF  THE  COENEA. 
ANAT03HY. 

Since  the  entrance  of  light  into  the  eye  depends  upon  the 
transparency  of  the  cornea,  the  diseases  which  affect  it  become 
of  the  utmost  importance  from  their  general  tendency  to  lessen 
its  clearness.  A  thorough  knowledge  of  the  complex  structure 
of  this  membrane  is  necessary  for  a  full  understanding  of  ita 
diseases  and  their  rational  treatment. 

The  cornea  forms  an  oval,  with  its  longest  diameter  horizon- 
tal; it  is  1.2  mm.  thick  at  its  insertion  into  the  sclera  and  about 
1  mm.  at  the  center;  while  thus  presenting  but  slight  thick- 
ness, its  tissue  is  very  tough  and  capable  of  resisting  consid- 
erable direct  pressure  without  danger  of  injury.  It  presents 
five  layers  for  examination  (Fig.  91):  1,  the  anterior  epithe- 
lial; 2,  anterior  elastic  membrane  (Bowman's);  3,  the  true 
corneal  tissue;  4,  a  posterior  elastic  membrane  (Descemet's)  j 
and  5,  a  posterior  endothelial  layer 

The  anterior  epithelium  is  continuous  with  that  of  the  con- 
junctiva of  the  bulb  and  consists  of  several  layers,  principally 
an  external  layer  of  flat  cells,  and  a  middle  layer  of  dentated 
cells,  which  overlie  a  layer  of  club-shaped  cells.  These  are 
all  held  together  by  a  cement  substance. 

The  anterior  elastic,  or  Bowman's  membrane,  upon  which 
these  latter  cells  rest,  is  a  fine,  minutely  fibrous  tissue  which 
gives  to  the  cornea  its  lustrous  appearance,  but  hardly  deserves 

235 


236 


DISEASES  AND  INJURIES  OF  THE  EYE. 


the  name  of  membrane,  as  it  appears  to  consist  mainly  of 
cement  substance  holding  fibrillae  and  fasiculi  which  can 
be  traced  into  the  true  corneal  tissue  which  underlies  it,  and 
from  which  it  is  inseparable.  This  also  passes  over  into  the 
conjunctival  tissue  together  with  the  first  lamella  of  the  cornea. 

The  true  corneal  tissue,  which 
forms  the  greater  bulk  of  the 
cornea,  is  made  up  of  from  sixty 
to  seventy  alternating  laminae 
which  are  arranged  parallel  to  the 
surface  of  the  cornea.  The  fibres 
of  which  the  lamellae  are  com- 
posed are  nearly  straight,  have  a 
definite  direction  in  each  layer, 
and  cross  each  other  at  right 
angles  in  the  alternate  layers. 
--  These  lamellae  are  not  separable 
'l^ZZZ  individually     owing     to     fibrillar 


"  binding  connections  between 

them.     Each  lamella  is  made  up 

of  numerous  bundles  of  fibrillee  of 

connective  tissue  intersecting  each 

other  at  various  angles  and  united 

^  by  cement  substance.     A  number 

of  these  form  a  fascicle  or  bundle, 

and  a  number  of  these  together 

T^r;  form  a  lamella.     In  this  portion 

::..^~'»  of  the  cornea  is  found  a  complex 

system    of    minute    canals   which 

— f>rr;-n  freely      anastomose     with      each 

,..-™,^-^m-r-T~:ri «:,-«- other  and  expand  into  lenticular 

FIG-  91-  shaped   spaces  or  lacunae ;  in  the 

latter  are  found  the  true  corneal  corpuscles,  which  consist  of 
masses  of  protoplasm  containing  a  large  nucleus  and  branch- 
ing processes  which  partially  fill  the  lacunae  and  extend  some- 
what out  into  the  canaliculi.  Other  varieties  of  cells  appear 
in  the  cornea,  some  which  seem  to  be  portions  of  the  fixed 


DISEASES  OF  THE  CORNEA.  237 

cells,  and  others  wandering  or  migratory  cells  similar  to 
white  blood  corpuscles,  and  at  the  margin  of  the  cornea  are 
found  pigment  cells  identical  with  those  of  the  sclera. 

This  system  of  canals  carries  the  nutritive  fluid  from  the- 
periphery  towards  the  centre  of  the  cornea,  the  corneal  tissue 
being  formed  from  the  migratory  and  fixed  cells.  The  corneal 
tissue  with  its  canals  passes  over  into  the  sclera.  The  true 
corneal  tissue  is  limited  internally  by  the  pDsterior  elastic 
membrane,  which  is  thicker  than  the  anterior  elastic  membrane, 
and  more  separable  from  the  overlying  tissue  than  the  latter. 
Upon  this  membrane  rests  a  single  layer  of  epithelial  cells 
held  together  by  cement  substance.  The  posterior  surface  of 
the  cornea  extends  further  back  than  the  anterior  so  that  it  ia 
slightly  overlapped  by  the  sclera. 

The  membrane  of  Descemet  is  a  firm,  structureless,  but  very 
elastic  membrane,  which,  at  its  circumference,  breaks  up  into 
trabecule  or  fibres  which  are  partly  continued  into  the  front  of 
the  iris  forming  the  ligamenium  jyeciinntum  iridis  and  partly 
into  the  anterior  portion  of  the  choroid  and  sclera.  That 
portion  forming  the  ligamentum  pectinatum  is  covered  with 
endothelial  cells.  These  cells,  however,  do  not  stretch  across 
the  intervals  between  the  processes,  but  leave  spaces  of 
communication  between  the  anterior  chamber  at  this  part  (the 
angle  of  the  iris),  with  the  canal  of  Schlemm. 

In  a  state  of  health  the  cornea  is  not  provided  with  blood- 
vessels except  at  the  circumference,  where  they  form  very  fine 
capillary  loops  and  accompany  the  nerves.  No  lymphatic 
vessels  are  discoverable  and  the  lymph  is  undoubtedly  carried 
on  by  the  canal  system  of  the  cornea. 

The  nerves  are  very  numerous  and  are  derived  from  the 
ciliary,  which  enter  the  fore  part  of  the  sclerotic,  and  are  from 
forty  to  forty-five  in  number.  They  become  transparent  soon 
after  entering  the  cornea  and  form  several  plexuses,  through 
its  structure  and  immediately  beneath  the  epithelium,  from 
which  branches  pass  forward  to  form  a  terminal  plexus 
amongst  the  epithelial  cells. 


238  DISEASES  AND  INJURIES  OF  THE  EYE. 

DISEASES  OF  THE  CORNEA. 

The  cornea  may  be  the  seat  of  inflammatory  action  which 
results  in  infiltration  of  its  structure,  changes  in  its  tissue,  or, 
its  destruction  in  whole  or  in  part.  These  pathological  changes 
may  be  superficial  or  deep,  and  consist  chiefly  of  an  infiltra- 
tion of  the  cornea  with  serum,  or  white  blood  corpuscles,  from 
the  marginal  vessels;  and  an  increase  of  its  cells  due  to 
proliferation,  as  in  the  diffuse  form  of  keratitis ;  or,  if  superficial 
and  circumscribed,  it  may  be  a  phlyctenular  inflammation. 
If  these  cells  are  aggregated  in  a  circumscribed  portion  so 
that  the  nutrition  of  the  underlying  layers  is  interfered  with, 
loss  of  substance  occurs  and  a  corneal  ulcer  results,  or,  if  the 
surrounding  tissue  does  not  give  way,  an  abscess  is  formed, 
and  if  the  infiltration  becomes  so  great  that  the  nourishment 
cannot  be  carried  on  through  its  natural  channels,  the  whole 
cornea  may  be  destroyed  by  the  suppurative  process.  In  the 
process  of  repair  the  new  tissue  is  not  always  as  regular  or  as 
transparent  as  the  other  portions  of  the  cornea,  but  is  cica- 
tricial, and  constitutes  an  opacity. 

KERATITIS  PHLYCTENULA.RIS. 

Herpes  corneoe,  Keratitis  pustulosa  or  phlyctenularis  (Plate 
III,  Fig.  1)  is  one  of  the  most  common  forms  of  corneal 
inflammation;  it  may  occur  in  adult  life  but  much  more 
frequently  appears  during  childhood.  The  particular  feature 
of  the  disease  is  the  occurrence  on  the  cornea  of  papules, 
vesicles,  or  pustules,  similar  to  those  which  characterize  phlyc- 
tenular inflammation  of  the  conjunctiva,  and  it  is  often  simply 
an  extension  of  that  disease.  When  situated  upon  the  margin 
of  the  cornea  they  are  frequently  small,  and  few  in  number, 
or  numerous  enough  to  encircle  its  periphery.  When  occur- 
ring upon  the  corneal  surface  they  may  be  single  or  multiple, 
but  there  is  always  a  bundle  of  minute  vessels  in  the  scleral 
conjunctiva  which  extends  to  the  vesicle,  and  when  a  leash  of 
vessels  is  developed  in  the  cornea,  as  frequently  happens  in 
these  cases,  the  term  fascicular  keratitis  has  been  applied  to 


PLATE   III 


^y^ 


Pblycbenular  Keratitis. 


DiFFuse      Keratitis. 


Hypopion  Keratitis 


Staphyloma    Corneae 


KERATITIS  PHLYCTENULARIS.  239 

it.  Aorain,  if  there  are  several  of  these  vescicles  the  whole 
conjunctiva  may  be  hyperasmic  and  present  a  catarrhal 
inflammation.  The  phlyctenules  consist  of  minute  elevations 
of  the  epithelial  layer  by  serous  infiltration,  probably  about 
the  terminal  filament  of  the  sensory  fibres  of  the  fifth  nerve. 
In  from  twenty-four  to  seventy-two  hours,  the  epithelial  cover- 
ing ruptures  and  more  or  less  corneal  substance  is  lost,  and  a 
small  ulceration  occurs,  accompanied  with  much  photophobia 
from  the  exposure  of  the  nerve  filaments.  If  the  case  is  a 
light  one,  the  epithelium  reforms  in  a  few  days  leaving  a  small 
hazy  portion  at  the  point  of  attack.  If  the  case  is  more 
severe,  there  is  a  greater  loss  of  the  cornea  and  the  ulceration 
is  deeper  and  may  perforate,  and  the  healing  process  proceeds 
more  slowly  and  leaves  a  flattened  surface  or  facet  at  the  point, 
and  a  cloudy  cicatrix  or  opacity  remains.  In  some  cases  the 
whole  cornea  is  seen  covered  with  these  small  ulcers,  and  blood- 
vessels becoming  developed  through  its  superficial  layers  con- 
stitute a  form  of  pannus.  In  bad  subjects,  one  phlyctenule 
follows  another,  or  successive  crops  appear,  and  the  disease 
lasts  for  months. 

Causes.  —  The  disease  results  from  mal-nutrition  and  im- 
proper hygienic  surroundings,  and  hence  is  largely  confined 
to  the  poorer  classes.  It  occurs  frequently  and  is  very  similar 
to  phlyctenular  inflammation  of  the  conjunctiva.  It  occurs 
during  dentition  and  at  the  age  of  puberty,  and  in  children  of 
a  strumous  habit,  or  who  live  almost  exclusively  upon  a  vege- 
table diet.  In  these  cases,  tlie  disease  becomes  obstinate, 
frequent  relapses  occur,  and  the  resulting  opacities  of  the 
cornea  interfere  very  greatly  with  the  vision.  It  is  often  a 
sequela  of  measles,  scarlet  fever,  and  whooping-cough. 

Symptoms.  —  The  symptoms  are  very  similar  to  those  of 
phlyctenular  inflammation  of  the  conjunctiva,  except  more 
marked  in  degree,  and  there  is  usually  considerably  more 
pain.  There  is  intense  photophobia  and  the  child  will  remain 
all  day  in  a  dark  corner,  or  lie  upon  the  bed  with  its  face 
buried  in  the  pillows  during  the  day,  endeavoring  to  exclude 
every  ray  of    light.        It  cannot  open  the  eyes,   and  if    the 


2-iO  DISEASES  AND  INJURIES  OF  THE  EYE. 

attempt  is  made  to  examine  them,  there  is  a  severe  blepharo- 
spasm, and  a  view  of  the  cornea  can  only  be  obtained  by  the 
use  of  a  retractor  under  the  upper  lid.  The  introduction  of 
an  elevator,  or  the  attempted  separation  of  the  lids  with  the 
tip  of  the  finger,  is  followed  by  a  gush  of  tears  and  the  cornea 
is  rolled  up  out  of  sight,  but  if  the  lid  is  kept  elevated  it  soon 
turns  down,  so  that  a  view  of  the  eyeball  is  obtained.  It  will 
then  be  found  that  one  or  more  small  points  of  ulceration  are 
present  on  the  cornea,  or  the  latter  may  be  very  vascular  and 
the  eyeball  injected.  If  the  case  is  severe  or  has  existed  for 
a  long  time,  the  conjunctiva  is  found  thickened  and  shows 
considerable  muco-purulent  discharge.  The  lids  are  thick- 
ened and  on  attempting  to  open  them  blood  frequently  comes 
from  the  fissures  at  the  external  canthus.  In  the  majority  of 
cases,  there  is  a  pustulous  eruption  on  the  parts  about  the  eye 
which  will  give  us  a  clue  to  the  condition. 

Treatment. — Attention  must  be  given  to  the  diet  of  the 
patient  and  it  should  be  made  as  nutritious  and  as  readily 
digestible  as  possible,  the  hygienic  surroundings  improved, 
and  warm  baths  daily  advised.  The  eyes  should  be  protected 
from  the  light  by  a  deep  shade,  or  dark  glasses,  or  a  very 
loose  bandage.  The  blepharospasm  may  be  temporarily  re- 
lieved, and  the  photophobia  lessened  by  the  use  of  ice-cold 
compresses  and  the  instillation  of  atropine  three  or  four  times 
a  day.  The  careful  selection  of  the  remedy,  according  to  the 
indications  here  given,  or  from  those  under  phlyctenular  con- 
junctivitis, with  a  proper  observance  of  the  hygienic  and 
dietic  part  of  the  treatment  will  result  in  a  prompt  cure  of 
these  cases  without  the  use  of  topical  applications. 

Arsenicum. — Pustules  appearing  after  measles;  conjunctiva 
very  red,  photophobia,  lachrymation,  and  thin,  burning  excori- 
ating discharge;  the  lids  may  be  pufiy  or  oedematous  and  the 
children  are  often  anaemic. 

Calc.  carb. — Large  phlyctenules  upon  the  cornea  which  have 
a  tendency  to  spread  and  ulcerate.  Photophobia  is  often  intense 
and  lachrymation  profuse.  The  lids  may  be  closed,  red  and 
swollen.     The  pains  are  more  likely  to  be  described  as  sticking. 


KERATITIS  PHLYCTENULARIS— TREATMENT.  241 

Cede.  iod. — When  the  tonsils  and  cervical  glands  are  swollen. 

Cole,  sulph.  — An  extremely  serviceable  remedy  when  the 
cervical  glands  are  enlarged.  "When  administered  in  the 
lower  potencies  brilliant  cures  often  follow. 

Graphiies.  —  Intense  photophobia,  so  that  the  child  cries 
fiom  pain  when  exposed  to  light,  and  must  be  kept  in  a  dark 
room.  The  lachrymation  is  often  profuse,  thin  and  acrid,  and 
there  is  burning  and  aching  in  the  eyes.  The  external  canthi 
are  fissured  and  bleed  easily.  There  is  often  an  eruption  on 
the  face  or  behind  the  ears.  The  nostril  is  frequently  exco- 
riated and  discharges  much  mucus,  or  is  covered  with  thick 
crusts.  If  this  aflfection  has  existed  for  a  long  time  the 
cornea  may  be  vascular  and  pannus  be  present. 

Hepar  suljjJi. — Phlyctenules  with  intense  photophobia,  pro- 
fuse lachrymation  and  great  redness  of  the  eyes.  The  pains 
are  throbbing  and  relieved  by  covering  the  eye,  and  from 
warmth. 

Mercurius  sol. — Pustulous  inflammation  following  measles 
or  scarlet  fever  with  severe  pains  which  are  continuous,  and 
aggravated  at  night.  The  photophobia  and  lachrymation  are 
variable.  The  lids  are  often  spasmodically  closed,  thick,  red 
and  swollen,  and  excoriated  from  the  acrid  lachrymation. 

Merc.  nit. — This  remedy  has  been  used  in  all  varieties  of 
phlyctenular  inflammation  with  marked  success. 

Pulsatilla.  —  Usually  in  cases  where  the  pustules  have 
extended  from  the  conjunctiva.  The  symptoms  are  all  mild 
and  the  photophobia  may  be  entirely  absent,  and  the  pains 
not  characteristic  and  not  always  present. 

Wilis  iox. — Small  phlyctenules  on  the  edge  of  the  cornea, 
often  forming  a  circle,  with  great  photophobia  and  profuse 
lachrymation.  Blepharospasm  is  commonly  present,  and  the 
child  lies  constantly  upon  the  face  making  every  endeavor  to 
exclude  the  light.  The  conjunctiva  is  very  red,  chemosed, 
and  the  lids  swollen  and  spasmodically  closed  retaining  a  large 
amount  of  tears  which  are  forced  out  on  attempting  to  open 
them.  '  ^ 

Sulphur. — The  symptoms  may  vary  greatly;  the  pains  are 
16 


242  DISEASES  AND  INJURIES  OF  THE  EYE. 

sharp  and  sticking  in  character,  worse  after  midnight,  and  the 
photophobia  is  usually  very  great,  the  lachrymation  may  be 
very  profuse  or  entirely  absent.  The  characteristic  eruption 
of  Sulphur  and  the  aggravation  from  bathing  in  cold  water, 
are  frequently  present. 

Among  the  other  remedies  which  may  be  selected  are  Apis., 
Croton  tig.,  Kali  bich.,  Kali  iod.,  Merc,  prot,  and  Nux  vomica. 

KERATITIS  ULCEROSA— CORNEAL  ULCERS. 

In  this  disease  we  have  a  softening  and  molecular  death  of 
a  portion  of  the  cornea  from  accummulation  of  the  infiltrated 
cells  at  that  point.  Various  forms  of  ulceration  of  the  cornea 
are  presented,  and  they  are  conveniently  divided  for  clinical 
purposes  into  two  classes,  the  sthenic  and  asthenic.  Those  of 
the  sthenic  type  are  accompanied  by  photophobia,  pain,  ciliary 
injection  and  lachrymation,  and  present  usually  a  grayish  base 
with  perhaps  swollen  edges,  or  the  infiltration  extending 
beyond  the  limits  of  the  ulcer.  In  the  asthenic  ulcer,  there  is 
little  or  no  pain,  photophobia  or  lachrymation.  Either  form 
may  be  superficial  or  deep.  Two  dangers  are  presented  in 
ulcerations  of  the  cornea,  viz:  changes  in  its  transparency  or 
opacities,  and  perforation  of  the  cornea  and  involvement  of 
the  iris  and  the  deeper  tissues  of  the  globe.  Corneal  ulcers 
may  present  an  acute  or  chronic  form;  in  the  former  the 
danger  of  perforation  is  greater,  while  in  the  latter,  opacities 
are  more  likely  to  result. 

Causes. — As  the  corneal  tissue  has  no  direct  blood  supply 
for  the  greater  portion  of  its  extent,  its  integrity  suffers  from 
any  cause  which  interferes  with  its  nutrition.  This  may  occur 
from  the  want  of  proper  nourishing  elements  in  the  blood,  as 
in  debilitated  subjects,  ill-nourished  and  scrofulous,  or  syphi- 
litic children,  or  after  prostrating  diseases  as  typhoid  fever, 
ansemia,  and  the  exanthemata.  Again  its  nutrition  may  be 
interfered  with  by  other  forms  of  keratitis,  or  violent  inflam- 
mations of  th^  conjunctiva^  which  obstruct  the  circulation  of 
blood  in  the  marginal  loops  of  the  cornea.     The  other  forms 


KERATITIS  ULCEROSA— CORNEAL  ULCERS.  243 

of  ulceration  arise  from  deficient  innervation,  A  great 
majority  are  of  traumatic  origin,  and  injuries,  even  when  very- 
slight,  may  in  weakened  patients  excite  extensive  ulceration. 

Symptoms.  —  The  chief  symptoms  of  ulceration  of  the 
cornea  are  photophobia,  congestion  and  pain,  which  vary 
greatly  in  different  cases.  The  photophobia  is  usually  more 
severe  in  superficial  than  in  deep  ulcers,  but  its  presence  in 
any  case  should  always  lead  to  a  careful  examination  of  the 
cornea.  The  congestion  consists  of  an  injection  of  the  vessels 
of  the  ciliary  region  and  in  some  cases  of  the  conjunctiva  as 
well.  The  pain  is  also  variable  and  is  commonly  referred  to 
the  parts  around  the  eye  rather  than  in  the  eye  itself. 

One  of  the  simplest  forms  of  corneal  ulcers  is  that  which 
occurs  in  phlyctenular  inflammation.  Another  variety  consists 
of  a  small  grayish  spot  of  infiltration  which  occurs  at  the  centre 
of  the  cornea,  which  in  the  first  stage  shows  a  slight  elevation, 
later,  a  depression,  and  the  infiltration  extends  somewhat 
around  the  ulcer  into  the  corneal  tissue.  The  patients  are 
young  and  poorly-fed  children.  The  ulcer  is  slow  to  heal  and 
generally  leaves  an  opacity,  or  may  spread  and  involve  a  large 
portion  of  the  cornea  in  suppuration. 

Another  variety  occurs  in  anaemic  and  strumous  children 
with  granular  lids;  one  or  more  ulcers  may  appear  and  be 
attended  with  little  infiltration,  and  after  a  chronic  course, 
finally  heal  and  leave  a  transparent  depression  or  facet. 

Superficial  ulcers  may  appear  without  much,  if  any,  infiltra- 
tion and  tend  to  extend  over  the  greater  portion  of  the  surface 
of  the  cornea,  while  other  forms  may  tend  to  involve  the 
deeper  layers  rather  than  the  superficial.  Again,  we  find 
other  forms  of  ulceration  which,  while  perhaps  not  of  great 
extent,  show  a  most  decided  tendency  to  perforation. 

The  infiltration  of  the  base  of  the  ulcer  is  variable,  or  it  may 
even  be  absent.  The  corneal  tissue  is  sometimes  thrown  off 
without  marked  infiltration  or  congestion,  as  in  the  chipping 
ulcers.  Again,  the  base  may  be  grayish,  white  or  even  yellow, 
and  the  infiltration  extend  to  a  variable  distance  into  the 
corneal  tissue. 


244  DISEASES  AND  INJURIES  OF  THE  EYE. 

Some  cases  present  a  development  of  blood-vessels  into  the^ 
ulcer  from  the  beginning,  as  in  vascular  ulcers,  or  when  occur- 
ring later  they  may  be  an  indication  of  repair,  bringing  an 
increased  amount  of  nourishment  to  the  part,  and,  as  the  ulcer 
heals,  dwindle  down  and  disappear. 

One  of  the  most  severe  forms  of  ulceration  is  the  serpiginous,, 
crescentic,  marginal,  or  ring  ulcer,  of  old  and  ill-nourished 
people,  or  occurring  during  the  progress  of  a  purulent  conjunc- 
tivitis. AVhen  occurring  in  elderly  people  it  is  often  slow  in 
its  progress,  but  cases  are  also  presented  where  it  is  rapid  and 
runs  its  course  in  one  to  two  weeks.  There  is  much  photo- 
phobia, pain  and  congestion.  A  small  excavation  appears  just 
within  the  corneal  margin  and  soon  extends  until  the  centre  is 
more  or  less  completely  surrounded  by  a  furrow,  which 
increases  in  depth,  until  the  inclosed  central  portion  of  the 
cornea  becomes  infiltrated  from  its  nutrition  being  cut  off,  and 
turns  grayish,  or  yellow,  and  sloughs  and  the  whole  cornea  is 
destroyed. 

Complications.  —  In  all  forms  as  the  ulceration  extends 
deeper  there  is  danger  of  perforation  of  the  cornea.  In  tlie 
majority  of  cases  the  corneal  tissue  is  destroyed  until  the 
membrane  of  Descemet  is  reached,  which  affords  some  resist- 
ance to  further  destruction  and  bulges  forward  from  the 
pressure  of  the  intra-ocular  tension  and  presents  as  a  small 
vesicle  in  the  floor  of  the  ulcer,  or  if  the  ulcer  is  of  great 
extent,  it  may  appear  as  if  the  process  of  repair  had  set  in  and 
the  ulcer  had  become  partially  filled.  In  all  cases  the  condi- 
tion should  be  examined  by  focal  illumination  which  will  reveal 
the  bulging  of  Descemet's  membrane  as  well  as  the  depth  and 
extent  of  the  ulceration.  If  there  is  no  interference  in  these 
cases  the  membrane  ruptures  and  the  contents  of  the  aqueous 
chamber  are  discharged,  and  the  iris  and  the  lens  move 
forward.  If  the  opening  is  large  the  iris  protrudes  through 
the  aperture,  forming  what  is  termed  a  prolapse  of  the  iris. 
The  protruded  portion  appears  as  a  brownish  nodule  surrounded 
by  the  grayish  or  yellowish  margin  of  the  ulcer.  If  the  lens 
comes  in  contact  with  the  internal  opening  in  the  cornea,  a. 


KERATITIS  ULCEROSA— CORNEAL  ULCERS.  245 

partial  capsular,  or  pyramidal  cataract,  results.  As  the  ulcera- 
tion heals,  the  iris  may  be  freed  by  the  establishment  of  the 
anterior  chamber  or  becomes  caught  in  the  cicatrix. 

Again,  in  some  cases,  the  opening  made  by  the  ulcer  becomes 
lined  by  the  endothelium  from  Descemet's  membrane  and 
exists  as  a  corneal  fistula;  in  this  case  a  minute  drop  of  aqueous 
may  be  seen  oozing  through,  when  pressure  is  made  upon  the 
globe,  and  the  depth  of  the  anterior  chamber  is  found  dimin- 
ished and  the  iris  drawn  forward  towards  the  opening. 

Hypopyon,  (Plate  III,  Fig.  3),  or  a  collection  of  pus  in  the 
anterior  chamber  is  a  complication  of  ulceration  when  the 
latter  arises  from,  or  takes  on,  a  suppurative  form. 

Treatment. — Ulcers  arising  during  the  inflammatory  affec- 
iions  of  the  conjunctiva,  or  cornea,  require  that  the  original 
aflfection  should  be  allayed  by  proper  treatment.  The  general 
•condition  of  the  patient  must  always  receive  attention.  In  all 
cases  of  ulceration  of  the  cornea,  atropine  solution  is  indicated 
and  should  be  applied  frequently  enough  to  cause  a  full  dilata- 
tion of  the  pupil.  Atropine  is  particularly  indicated  if  the 
ulcer  is  central  and  sthenic.  If  peripheral  and  asthenic  an 
eserine  solution  is  more  suitable.  As  the  discharge  from  the 
conjunctiva  or  ulcer  is  often  septic  and  irritating,  the  use  of  a 
solution  of  boracic  acid  (gr.  x  ad  fsi),  or  dilute  chlorine  water 
(1  to  3),  dropped  into  the  eye  every  hour  or  two,  will  aid 
materially  the  process  of  repair.  If  the  ulcer  is  sthenic,  rest 
in  bed  and  cold  applications,  together  with  the  use  of  atropine 
or  eserine  are  necessary.  A  non-stimulating  diet  should  be 
prescribed.  If  asthenic,  hot  fomentations  or  hot  compresses 
should  be  used,  atropine  or  eserine  as  before,  and  a  generous 
and  stimulating  diet. 

A  pressure  or  retaining  bandage  will  often  prevent  the 
extension  of  the  ulceration,  secure  rest  and  hasten  repair.  If 
the  floor  of  the  ulcer  is  very  thin  it  is  better  to  avoid  sponta- 
neous rupture  by  opening  the  anterior  chamber  by  the  opera- 
tion of  paracentesis  corneal,  which  is  made  with  a  Desmarre's 
paracentesis  knife  (Fig.  92),  or  a  broad  needle  (Fig.  93) ;  the 
lids  are  held  apart  and  the  eyeball  held  by  a  pair  of  fixation 


246  DISEASES  AND  INJURIES  OF  THE  EYE. 

forceps,  the  knife  is  passed  through  the  cornea  near  the 
Bclero-corneal  junction  below,  or  at  the  outer  side  and  inde- 
pendent of  the  seat  of  ulceration.  After  the  knife  has  entered 
the  anterior  chamber,  taking  care  to  avoid  wounding  the  iris 
or  lens,  or  causing  a  prolapse  of  the  iris,  it  is  then  slowly 


^^ 


FIG.  92. 


withdrawn,  slight  pressure  being  made  at  the  same  time  upon 
the  lower  margin  of  the  wound.  The  operation  is  not  very- 
painful  and  may  be  done  without  ether.  The  wound  may 
require  opening  daily  with  a  fine  probe  until  all  danger  is 
pasi 

Simple  puncture  of  the  floor  of  the  ulcer  by  a  fine  needle 
may  be  sufficient,  and  the  aqueous  allowed  to  drain  off  slowly, 
care  being  taken  to  prevent  wounding  the  iris  or  lens  during 
the  proceeding.  This  must  be  repeated  as  often  as  may  be 
necessary  to  relieve  the  pressure.  The  patient  must  be  con- 
fined to  bed  and  atropine  or  eserine  used,  and  a  pressure 
bandage  applied.  Where  the  ulceration  is  deep  or  exhibits  a 
suppurative  tendency,  Saemisli's  operation  as  proposed  for  the 
serpiginous  ulcer  may  be  used.     The  point  of  a  narrow  cata- 


ract knife  is  introduced  into  the  sound  tissue  on  the  temporal 
side  of  the  ulcer,  passed  into  the  anterior  chamber  and  then 
carried  through  the  aqueous  humor  beneath  the  centre  of  the 
ulcer,  and  made  to  emerge  in  the  sound  corneal  tissue  on  the 
other  side  of  the  ulcer.  The  knife  is  then  made  to  cut  its  way 
through  the  cornea  to  prevent  the  sudden  expulsion  of  the 
aqueous.  Although  the  sensibility  is  not  very  great,  it  is 
permissible  to  use  ether  for  the  operation.  The  wound  will 
have  to  be  opened  daily  with  a  fine  probe  or  Weber's  probe- 
pointed  lachrymal  knife  (Fig.  94). 


CORNEAL  ULCERS— REMEDIES.  247 

After  any  of  these  surgical  procedures  atropine  or  eserine, 
as  may  be  achdsable,  should  be  instilled  and  the  pressure 
bandage  applied. 

When  fistula  of  the  cornea  occurs  or  remains  after  the 
ulcerated  process  has  passed,  the  opening  may  be  closed  by 
touching  it  lightly  with  a  fine  point  of  lunar  caustic  and  a 
bandage  applied,  or  the  surface  of  the  fistula  abraded  with  a 
fine  cataract  needle.  If  these  procedures  fail,  the  application 
of  poultices  may  produce  sufficient  stimulation  to  close  it,  or 
an  iridectomy  may  have  to  be  made. 

The  results  of  ulceration  of  the  cornea  are  opacity,  anterior 
synechia,  prolapse  of  the  iris,  keratocele,  and  leucoma  adhe- 
rens or  adhesion  of  the  iris  to  the  cicatrix. 

REMEDIES. 

Aconite. — Superficial  ulcers  arising  from  injuries.  It  may 
be  used  both  internally  and  externally. 

Arsenicum. — Corneal  ulcers  occurring  in  weak  anaemic  chil- 
dren. They  are  often  superficial  and  have  a  tendency  to  recur. 
The  photophobia  is  excessive  and  the  lachrymation  acrid  and 
burning.  The  pains  are  more  frequently  burning  and  aggra- 
vated after  midnight.  Small  grayish  central  ulcers  which 
occur  in  young  diildren  and  tend  to  perforate. 

Aurum. — Vascular  ulceration  of  the  cornea  and  ulcerations 
occurring  during  the  course  of  pannus,  or  as  the  result  of 
abscess.  There  is  much  photophobia,  profuse  scalding  lachry- 
mation and  sensitiveness  of  the  eye  to  touch,  and  pains  appar- 
ently extending  from  the  parts  around  the  eye  to  the  eye,  and 
aggravated  by  touch. 

Calc.  carh.  and  Cede,  hyperphos. — Ulcerations  occurring  in 
ill-nourished  patients  which  show  a  tendency  to  slough,  or 
which  result  from  abscess. 

Conium.  —  Some  superficial  ulcers  without  much  pain  or 
redness  but  with  intense  photophobia. 

Graphites. — In  some  cases  of  ulceration  of  the  cornea  which 
have  followed  attacks  of  phlyctenular  inflammation  of  the 
cornea  or  conjunctiva. 


248 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Hepar  sulphur.  —  A  valuable  remedy  for  all  ulcers  or 
abscesses  where  there  is  pus  in  the  anterior  chamber.  There  is 
usually  a  marked  sloughing  tendency  and  the  pain  is  throbbing 
and  the  photophobia  intense,  while  the  conjunctiva  is  often  red 
and  thickened  or  chemosed.  There  is  relief  generally  from 
bandaging  the  eye  and  the  application  of  warm  compresses, 
although  there  is  great  sensitiveness  of  the  eye  to  touch. 

Ignatia. — Small  chipping  ulcers  without  much  discomfort, 
which  occur  in  connection  with  derangements  of  the  digestion ; 
also  small  pinhole  ulcers  which  are  attended  by  photophobia 
and  sensation  as  if  something  was  in  the  eye,  in  nervous  and 
hysterical  patients. 

Mercurius. — Often  indicated  in  both  superficial  and  deep 
ulcerations.  There  is  generally  grayish  infiltration  of  the 
base  and  around  the  ulcer  which  is  also  often  vascular.  The 
discharges  from  the  eye  are  profuse,  thin  and  excoriating. 
There  is  a  general  aggravation  at  night.  Concomitant  symp- 
toms more  frequently  decide  upon  the  particular  form  of 
Mercury  to  be  administered;  the  eye  symptoms  indicating 
Merc.  cor.  being  more  intense  and  there  is  much  ciliary  injec- 
tion and  pain. 

Merc,  nit — More  useful  in  those  ulcerations  which  partake 
of  a  phlyctenular  character. 

Merc.  proi. — Ulcerations  occurring  with  pannus;  its  efficacy 
in  ulcus  serpens  is  very  doubtful  and  it  has  not  proved  as  use- 
ful as  Calc.  phos.  or  Silicia  in  these  cases. 

Nux  Vomica  and  Pulsatilla  suit  some  cases  of  superficial 
ulceration  with  intense  photophobia,  and  it  becomes  very 
difficult  to  difierentiate  between  them  when  marked  concomi- 
tant symptoms  are  not  present. 

Silicia. — Indicated  in  some  cases  of  sloughing  ulcers  of  the 
cornea,  as  in  the  marginal  ulcer,  and  when  small^  funnel- 
shaped  non-vascular  ulcers  appear  near  the  centre  of  the  cornea 
and  rapidly  perforate. 

Sulphur.— W\iQri  the  ulceration  is  indolent  and  tends  to 
slough  this  remedy  will  be  useful.  There  is  often  considerable 
infiltration  around  the  ulcer  but  no  vascularity.     The  photo- 


KERATITIS:  INTERSTITIAI^  NON-VASCULAR.  249 

phobia,  lachrymation  and  other  symptoms  ,are  variable.  The 
fibarp  sticking  pains  which  are  commonly  present  and  worse 
after  midnight  are  very  characteristic.  The  subjects  are 
strumous  and  the  general  condition  is  indicative  of  Sulphur. 
Many  other  remedies  may  have  to  be  consulted  for  individual 
cases. 

KERATITIS  DIFFUSA. 

Parenchymatous  or  Interstitial  Keratitis  (Plate  III,  Fig,  2) 
is  the  result  of  an  infiltration  of  the  corneal  tissue  from  a 
proliferation  of  the  corneal  cells  without  changes  in  the 
epithelium  or  anterior  elastic  membrane.  Both  eyes  are 
usually  affected,  but  an  interval  of  several  weeks,  or  months, 
generally  exists  between  the  onset  of  the  disease  in  the  two 
eyes,  the  second  being  perhaps  attacked  while  the  first  is 
recovering.  The  disease  runs  a  protracted  and  tedious  course 
extending  over  six  or  tAvelve  months,  but  as  the  cornea  rarely 
ulcerates  the  infiltration  gradually  disappears  and  leaves  the 
cornea  clear,  and  if  the  iris  or  choroid  have  not  been  impli- 
cated slight  or  no  permanent  damage  is  done.  Two  forms  are 
to  be  considered,  one  characterized  by  dense  infiltration  without 
development  of  vessels  in  the  cornea  and  the  other  presenting 
a  general  vascular  condition  of  the  cornea.  They  are  both 
local  manifestations  of  a  constitutional  derangement  of  the 
system. 

DIFFUSE  NON-VASCULAR  KERATITIS. 

Symptoms. — The  non-vascular  form  begins  with  a  haziness  of 
the  cornea  which  may  be  central  or  marginal.  This  cloudiness 
becomes  more  opaque  and  advances  slowly  over  the  cornea 
until  the  whole  surface  is  covered  and  presents  a  steamy  or 
ground-glass  appearance,  having  lost  its  transparency  and 
lustre,  and  hides  the  iris  from  view.  This  opacity  will  A-ary 
with  different  cases  in  different  portions  of  the  cornea  from  a 
slight  haziness  to  a  dense  white  opacity,  or  present  more  dense 
spots  in  some  points  than  in  others.  Occasionally  yellow  spots 
are  seen.     When  the  inflammation  has  reached  its  height  the 


250 


DISEASES  AND  INJURIES  OF  THE  EYE. 


corneal  epithelium  presents  a  stippled  appearance  as  if  pricked 
with  a  needle.  With  the  beginning  of  the  infiltration  there  is 
slight  photophobia  which  may  be  more  marked  later,  or  disap- 
pear. There  is  slight  ciliary  injection  which  increases  as  the 
disease  progresses,  or  upon  exposure  to  light  during  exami- 
nation, or  from  irritation.  The  conjunctiva  is  scarcely  affected 
and  there  is  usually  slight  lachrymation.  Pain  may  be  entirely 
absent  except  by  exposure  of  the  eye  to  light  or  if  the  iris 
becomes  implicated. 

Causes. — The  most  common  cause  is  hereditary  syphilis. 
It  appears  during  the  ages  of  six  and  fifteen,  sometimes  as 
early  as  three ;  rarely  later  than  twenty.  When  occurring  in 
adult  life  it  may  be  the  result  of  acquired  syphilis,  and  occurs 
with  the  secondary  symptoms,  or  in  women  it  may  be  occa- 
sioned by  some  uterine  disease.  No  assignable  cause  can  be 
found  for  it  in  other  cases.  When  the  disease  appears  in 
children,  other  symptoms  of  constitutional  syphilis  will  be 
present  in  the  child  or  mother.     The  child  may  present,  per- 


jjf,1T-iirj;p|r.  nip,j.  ;:-ryim,m. 


FIG.  96. 


haps,  evidences  of  a  former  iritis  or  some  of  the  well-known 
signs  of  inherited  syphilis  in  the  teeth,  skin,  bones  or  physi- 
ognomy. The  most  distinctive  of  these  are  the  notched  teeth 
of  Hutchinson  as  shown  in  Figs.  95  and  96.  The  evidence  of 
congenital  syphilis,  as  exhibited  by  the  teeth,  consists  in  a 
crescentic  notch  in  the  lower  margin  of  the  central  incisors  of 
the  permanent  teeth,  giving  them  a  chisel-like  appearance, 
while  the  later  incisors  and  canines  are  often  peg-shaped  and 
irregularly  placed  in  the  jaw.  This  condition  of  the  teeth 
should  not  be  mistaken  for  the  serrated  margins  of  the  per- 
manent teeth,  which  are  more  frequently  found  in  children 
who  have  suffered  from  prostrating  diseases  during  the  early 
periods  of  the  development  of  the  teeth  of  second  dentition. 
The  skin  in  these  patients  often  presents  a  peculiar  yellowish 


KERATITIS:  NON-VASCULAR— VASCULAR.  251 

or  earthy  color  and  is  loose  and  soft,  and  if  the  protuberant, 
square  forehead,  or  broad,  flattened  nose  bridge,  and  diseased 
condition  of  the  bones  occur,  the  evidences  of  inherited 
syphilis  are  complete. 

Treatment. — No  local  treatment  is  necessary  beyond  the 
use  of  a  solution  of  atropine  if  there  is  much  pain  or  iritia 
complication.  The  duration  of  the  disease  is  much  shortened 
by  the  proper  homoeopathic  remedy  and  a  nutritious  diet. 

REMEDIES. 

Aurum  wttif*— This  preparation  is  the  one  most  frequently 
indicated  in  these  cases  of  syphilitic  keratitis.  The  symptoms 
are  those  of  diffuse  infiltration  with  moderate  photophobia, 
and  pain  which  is  of  a  dull  character  and  referred  to  the  parts 
about  the  eye. 

Mercurms  sol. — The  inflammation  is  more  active;  there  is 
usually  more  pain,  greater  ciliary  injection  and  nocturnal 
aggravation  than  under  Aurum,  and  the  general  concomitants 
of  Mercury  are  present. 

Mercurius  prot. — Often  useful  when  Merc.  sol.  does  not  act' 
promptly. 

Arsenicum.  —  Diffuse  keratitis  with  marginal  vascularity. 
The  photophobia  is  intense,  the  lachrymation  profuse,  and 
burning  pains  are  complained  of.  The  aggravation  after 
midnight,  restlessness  and  thirst  are  commonly  present. 

Apis  mel. — With  the  infiltration  of  the  cornea  there  is 
moderate  injection  of  the  ciliary  region  and  photophobia. 
Febrile  disturbance,  thirstlessness,  and  drowsiness  often 
accompanying  the  condition. 

Hepar  siilplnir. — Often  serviceable  when  there  is  much 
ciliary  injection  or  pain,  great  photophobia,  lachrymation  and 
sensitiveness  of  the  eye  to  touch. 

Baryta  iod. — "When  enlargement  of  the  cervical  glands, 
which  are  hard  and  painful  on  pressure,  accompany  the  dis- 
eases of  the  cornea. 

Kali  mur. — Interstitial  keratitis  with  occasional  pain,  mod- 
erate photophobia  and  redness. 


"252  DISEASES  AND  INJURIES  OF  THE  EYE. 

Sepia. — Diffuse  keratitis,  occurring  in  women  suffering  from 
uterine  diseases. 

DIFFUSE  VASCULAR  KERATITIS. 

The  vascular  form  begins  as  in  the  first  variety;  the  cornea 
l)ecomes  infiltrated  and  hazy,  but  soon  numerous  small  vessels 
«,re  developed  through  it.  They  give  to  the  cornea  the  appear- 
ance of  spots  of  effused  blood,  or  when  the  number  of  vessels 
is  still  more  increased,  the  cornea  assumes  a  dull  red  or  fleshy 
appearance.  The  epithelium  is  loosened  in  some  cases,  but 
ulceration  rarely  follows.  It  occurs  more  ofl»n  between  the 
4iges  of  ten  and  twenty  years.  Its  course  and  duration  are 
«,bout  the  same  as  the  non-vascular  form.  The  photophobia, 
injection  and  pain  are  rarely  more  severe  than  in  the  simple 
'diffuse  form  of  keratitis,  and  as  the  disease  progresses,  the 
vessels  disappear  and  the  cornea  again  becomes  clear,  though 
small  spots  of  infiltration  and  a  clouding  of  the  cornea  may 
present  for  a  long  time.  The  disease  is  liable  to  be  mistaken 
for  pannus,  but  the  smoothness  of  the  cornea  and  the  absence 
.of  a  granular  condition  of  the  conjunctiva  of  the  lids  will 
prevent  an  error  of  diagnosis. 

Causes. — The  causes  are  virtually  the  same  as  those  of  the 
jion-vascular  form,  and  will  appear  in  patients  presenting 
■evidences  of  congenital  syphilis.  This  variety  occurs  much 
more  frequently  in  strumous  children  presenting  granular 
-enlargement,  and  in  girls  at  the  age  of  puberty. 

Treatment. — This  is  the  same  as  that  of  the  diffuse  form, 
and  of  the  remedies  already  considered  in  that  condition, 
Aurum,  Arsenicum,  Baryta  iod.  and  Hepar  are  more  likely  to 
he  indicated;  in  addition  to  these,  Cannabis  sat.  and  Calc. 
phos.  may  be  called  for.  After  the  inflammatory  symptoms 
of  either  form  have  subsided  Hepar  s.,  Calc,  Aurum  mur.  and 
Sulphur  will  be  useful  to  clear  up  the  opacities  remaining. 

Pannus  or  Superficial  Vascular  Keratitis  occurs  when 
"the  epithelial  layer  of  the  cornea  is  irritated,  blood-vessels 
Toeing  developed  in  the  epithelial  layer  from  the  capillary 
loops  at  its  periphery.     It  occurs  as  a  result  of  the  irritation 


KERATITIS  SUPPURATIVA.  253S 

of  the  granular  deposits  in  trachoma  or  froija  the  inversion  of 
the  cilia.  It  also  t^ppears  in  severe  cases  of  phlyctenular 
keratitis.  It  differs  from  the  disease  just  described,  in  that 
the  vessels  are  well  defined  and  distinct,  and  the  corneal 
opacity  is  more  dense.  It  begins  on  the  upper  portion  of  the 
cornea  beneath  the  upper  lid. 

When  pannus  exists  for  a  long  time  it  may  lead  to  softening 
and  bulging  of  the  corneal  tissue. 

Treatment. — Pannus  disappears  when  the  cause  of  the  irri- 
tation has  been  removed,  and  its  treatment  has  already  been 
considered  under  trachoma  and  phlyctenular  keratitis. 

KEKATITIS  SUPPURATIVA. 

Abscess  of  the  cornea  is  "characterized  by  a  more  or  less 
local  infiltration  of  pus  cells  to  such  an  extent  that  a  part  or 
the  whole  of  its  structure  is  destroyed.  The  anterior  layera 
of  the  cornea  may  break  down  and  ulceration  occur,  or  if  the 
underlying  layers  are  destroyed,  the  pus  is  evacuated  into  the 
anterior  chamber  and  hypopyon  results,  or  again,  the  pus. 
may  cause  a  separation  of  the  lamellae  of  the  cornea  and 
sinks  down  to  the  lower  portion  forming  an  onyx.  The  infiU 
•  tration  may  begin  at  one  point,  either  central  or  peripheral, 
and  show  a  yellowish  spot  or  abscess,  or  may  begin  at  the 
periphery  and  extend  around  the  cornea  forming  a  circular  or 
ring  abscess,  and  later  the  whole  cornea  becomes  infiltrated 
and  sloughs.  The  process  may  stop  at  any  point  and  repair 
take  place.  Opacity  is  likely  to  remain  from  the  destruction 
of  the  corneal  tissue  and  its  repair  by  less  transparent  material. 
Two  varieties  of  the  disease,  acute  and  sub-acute,  are  de- 
scribed, but  they  present  no  distinctive  clinical  features  as  the 
symptoms  of  each  form  vary  much.  The  acute  variety  is  of  a 
more  sthenic  character,  with  severe  congestion,  pain  and  pho- 
tophobia; while  in  the  sub-acute  forms  there  may  be  almost 
entire  absence  of  acute  inflammatory  symptoms,  pain  and 
photophobia,  but  the  disease  progresses  rapidly  to  the  com- 
plete destruction  of  the  cornea. 


254 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Causes. — The  acute  form  generally  occurs  in  feeble  con§ti 
initions  as  a  result  of  injury,  operations  upon  the  cornea  as  in 
cataract  extraction,  cold  and  severe  inflammation  of  the  con- 
junctiva, as  in  ophthalmia  neonatorum  and  other  varieties  of 
purulent  conjunctivitis.  The  sub-acute  form  affects  persons 
who  exhibit  a  low  condition  of  the  system,  due  to  want  of 
nourishment,  or  is  the  result  of  debilitating  diseases  as  variola, 
phthisis,  typhus,  or  cholera,  and  in  delicate,  weak,  children  who 
do  not  receive  proper  nourishment. 

Symptoms,  Diagnosis  and  Prognosis. — In  the  acute  variety, 
there  is  violent  and  severe  pain  which  is  referred  to  tha 
eyebrow  and  temple^  photophobia,  lachrymation  and  ciliary 
injection,  with  perhaps  chemosis  and  blepharospasm.  The 
cornea  is  hazy  and  some  portions  present  a  grayish  infiltration 
which  soon  becomes  yellow  at  some  point.  The  pus  may 
escape  externally  and  an  ulcer  form,  or  open  into  the  anterior 
chamber,  or  gravitate  between  the  corneal  layers.  If  the  pus 
does  not  find  an  exit  the  whole  cornea  becomes  involved  in 
the  purulent  infiltration. 

In  mild  cases  under  proper  treatment  the  disease  disap- 
pears, leaving  behind  only  a  slight  corneal  opacity;  in  more 
severe  cases  the  hypopyon  and  iritis  increase,  the  ulceration  , 
spreads  and  perforation  of  the  cornea  may  take  place,  and  a 
large  permanent  cicatrix,  with  perhaps  adhesions  of  the  iris, 
occurs,  and  the  suppurative  process  involves  the  whole  eyeball. 
The  course  of  the  disease  depends  upon  the  amount  of  tissue 
involved  and  whether  ulceration  or  hypopyon  follows.  The 
iris  is  apt  to  be  involved  and  iritis  results  which  increases  the 
danger. 

In  the  sub-acute  form  there  is  no  marked  symptom  of 
inflammation,  and  the  pain  and  photophobia  are  slight  or 
absent.  The  prognosis  depends  upon  the  amount  of  cornea 
involved  and  its  situation;  if  superficial,  ulceration  occurs,  if 
more  deep,  the  inflammatory  process  extends  to  the  iris  and 
choroid,  the  conjunctiva  becomes  congested  and  the  destruc- 
tion of  the  cornea  progresses  still  more  rapidly.  The  prog- 
nosis then  is  generally  unfavorable,  but  depends  upon  the  seat, 
depth  and  extent  of  the  suppurative  process. 


KERATITIS  SUPPURATIVA— TREATMENT.  255 

-  Treatment. — Attention  to  diet  is  necessary  and  often  a  gen- 
erous or  stimulating  diet  may  be  demanded.  In  slight  cases 
rest,  the  use  of  atropine  locally  and  a  pressure  bandage, 
together  with  the  use  of  Hepar  s.,  Calc  phos.,  or  Sulphur  is 
all  that  is  necessary,  the  pressure  bandage  being  contra-indi- 
cated in  violent  inflammatory  forms  with  profuse  conjunctival 
secretion.  In  the  acute  form,  cold  applications  may  be  used 
locally  if  pleasant  to  the  patient,  and  in  the  sub-acute  variety 
when  it  arises  from  conjunctival  inflammation,  but  if  the  cold 
applications  are  not  comfortable,  hot  applications  should  be 
used.  Hot  fomentations,  by  means  of  light  compresses  soaked 
in  water  as  hot  as  can  be  borne,  are  to  be  applied  for  ten  or 
fifteen  minutes  at  a  time,  every  two  hours,  until  improvement 
is  perceptible,  when  the  applications  must  be  made  at  longer 
intervals.  If  the  abscess  shows  no  signs  of  absorption,  it  may 
be  opened  with  the  point  of  a  cataract  knife,  but  this  is  rarely 
necessary  under  homoeopathic  treatment.  If  ulceration  occurs, 
it  is  to  be  treated  as  already  described.  If  hypopyon  results,  the 
use  of  eserine  may  be  indicated,  or  paracentesis  of  the  cornea 
may  be  necessary.  Perforation  of  the  cornea  is  to  be  prevent- 
ed by  the  means  advised  in  the  treatment  of  corneal  ulcers. 

The  remedies  useful  in  this  form  of  corneal  trouble  are 
Hepar  sulph.,  Calc.  carb.,  Calc.  hyperphos.,  Merc  sol.,  Silic, 
and  Sulphur,  according  to  the  indications  given. 

Hepar  sulph. — Abscess  and  sloughing,  or  sloughing  ulcers, 
of  the  cornea,  when  accompanied  by  hypopyon.  Photophobia 
intense,  lachrymation  profuse,  and  there  is  great  redness  of 
the  cornea  and  conjunctiva,  with  severe  aching,  throbbing 
pains;  relief  from  warm  applications,  and  aggravation  from 
colds.     There  is  marked  sensitiveness  of  the  eye  to  touch. 

Calc.  carb. — Cases  occurring  in  children  with  the  concom- 
itant indications  of  calcarea.  The  pains,  redness  and  photo- 
phobia are  variable. 

Calc.  hyperphos. — In  weak,  debilitated  individuals  where 
there  is  great  purulent  infiltration  and  tendency  to  sloughing. 

Calc.  sulph. — Very  useful  in  many  cases  of  purulent  infil- 
tration of  the  cornea  occurring  in  debilitated  subjects. 


256  DISEASES  AND  INJURIES  OF  THE  EYE. 

Merc.  sol. — In  abscess  of  the  cornea  when  there  is  a  gray- 
ish infiltration  extending  some  distance  beyond  the  abscess. 
The  conjunctival  redness  and  photophobia  are  marked,  while 
the  lachrymation  may  be  profuse  and  acrid.  There  is  aggra- 
vation of  the  condition  at  night  and  from  either  very  cold  or 
very  warm  applications. 

Silicia. — Abscess  of  the  cornea  with  hypopyon.  The  pain, 
photophobia  and  redness  are  not  characteristic.  There  is, 
generally,  relief  from  wrapping  the  head  or  bandaging  the  eye. 

Sulphur. — Not  infrequently  indicated  in  suppurative  inflam- 
mation of  the  cornea  in  strumous  constitutions.  The  sharp 
sticking  pains  of  the  eyeball,  which  occur  more  often  after 
midnight,  are  very  characteristic. 

Neueoparalytic  Keratitis  is  a  somewhat  rare  disease 
which  occurs  in  consequence  of  wounds  or  injuries  of  the 
superficial  branches  of  the  fifth  nerve,  or  paralysis  of  the  nerv'^e 
itself  due  to  intra-cranial  causes.  There  is  loss  of  sensibility 
of  the  cornea,  the  conjunctiva  becomes  dry,  and  the  cornea 
cloudy,  infiltrated,  and  is  rapidly  destroyed.  The  intra-ocular 
tension  is  lessened.  In  some  cases  the  presence  of  a  foreign 
body  in  the  folds  of  the  conjunctiva,  or  slight  injuries  of  the 
cornea,  seem  adequate  to  produce  sufficient  innervation  in 
debilitated  subjects  to  impair  the  nutrition  of  the  cornea. 

Treatment — The  removal  of  the  cause  and  the  application 
of  a  bandage  will,  in  slight  cases,  suffice  to  cause  a  return  to 
the  normal  condition.  In  any  case,  the  eye  should  be  pro- 
tected from  external  irritation  by  the  closure  of  the  lids  and 
the  same  treatment  used  as  in  other  forms  of  corneal  suppura- 
tion. In  addition  the  use  of  the  constant  galvanic  current  will 
prove  of  value. 

Keratitis  Punctata  or  Descemeiltis  is  a  term  given  to  the 
dotted  opacities  which  occur  upon  the  membrane  of  Descemet. 
It  is  almost  always  the  result  of  disease  of  the  iris  or  ciliary 
body.  When  originating  in  the  cornea,  there  is  usually  slight 
pain  or  considerable  ciliary  injection,  with  dimness  of  the 
vision  from  the  changes  of  the  endothelium.  The  punctated 
appearance  takes  a  triangular  form  with  the  apex  towards  the 


CORNEAL  OPACITIES.  .  257 

centre  of  tlie  cornea.     The  disease  is  apt  to  be  protracted  and 
tedious. 

Treatment — Gelsem.  and  Kali  bich.  and  the  use  of  atropine 
are  sufficient  to  clear  up  the  condition  in  the  majority  of  cases. 
Those  cases  occurring  during  the  progress  of  iritis  and  cyclitis 
will  be  considered  in  the  chapter  devoted  to  these  diseases. 

CORNEAL   OPACITIES. 

Every  possible  variety  of  opacity  as  regards  extent  and 
density  occur  as  the  result  of  inflammatory  changes  in  the 
cornea.  Slight  opacities,  due  to  the  healing  of  superficial 
ulcers  are  called  nehulcB  or  maculce;  when  they  occur  in  very 
young  children  they  may  disappear  entirely.  Dense  white 
opacities,  leiicomaia,  occur  as  a  result  of  deep  ulcers.  Even 
these,  in  children,  may  clear  up  considerably  in  time.  If  the 
entire  cornea  is  opaque  the  condition  is  known  as  leucoma 
totalis.  If  the  iris  is  adherent  to  the  cicatricial  tissue,  it 
forms  a  leucoma  adherens. 

The  effect  upon  the  vision  depends  largely  upon  its  situation 
and  density.  If  central,  even  the  most  delicate  clouding  is 
very  destructive  to  vision,  while  very  dense  opacities,  if  the 
centre  be  clear,  do  not  interfere  materially  with  the  vision. 

These  opacities  are  not  infrequently  productive  of  squint, 
and  also  cause  a  blemish  which  the  patient  is  always  anxious 
to  have  removed. 

Improvement  in  the  condition  may  be  expected  as  long  as 
the  inflammation  which  caused  the  opacity  continues,  but  no 
improvement  is  likely  to  take  place  after  that  has  disappeared. 

Treatment. — The  internal  administration  of  Calcarea, 
Aurum,  Hepar,  Cannabis,  and  Silicia,  will  oftentimes  cause  a 
very  rapid  and  wonderful  improvement  in  the  transparency  of 
these  cicatricial  spots.  The  application  of  some  stimulant 
directly  to  the  opaque  portion  is  usually  indicated  where  there 
is  no  vascularity  of  the  cornea  remaining.  For  this  purpose 
a  great  variety  of  solid  and  liquid  irritants  have  been  used. 
Almost  anything  which  will  produce  a  slight  irritation  of  the 
cornea  which  lasts  for  fifteen  or  twenty  minutes  will  be  useful. 

17 


258 


DISEASES  AND  INJURIES  OF  THE  EYE. 


The  following  have  proved  very  useful  when  applied  directly 
to  the  opacity:  sulphate  of  soda,  kali  bich.,  calomel,  sulphate 
of  copper  and  aluminate  of  copper.  Recently,  I  have  had 
most  excellent  results  from  the  application  of  Eesorcin,  in 
powder,  to  the  opacity. 

Stenopaic  glasses  by  lessening  the  irregular  refraction  of 
light  may  be  beneficial,  but  are  rarely  worn.  If  a  clear 
portion  of  the  cornea  remains,  then  an  iridectomy  by 
making  a  new  pupil  will  materially  improve  vision. 
Finally,  an  opacity  of  the  cornea  which  is  white  and 
conspicuous  may  be  tattooed  with  india  ink,  by  means 
of  a  small  bundle  of  fine  needles  as  in  Fig.  97.  The 
lids  should  be  held  apart  by  the  speculum,  and  the 
cornea  dried  by  absorbent  cotton  which  is  also  used  to 
prevent  the  washing  away  of  the  ink,  which  is  pricked 
into  the  substance  of  the  cornea  by  the  needles.  A 
fjl  fine-pointed  steel  pen  is  often  more  efficient  than  the 
ll^  needles.  Several  sittings  will  usually  be  required. 
The  irritation  follo^\'ing  the  introduction  of  the  ink  is 
usually  not  very  great.  The  ink  is  absorbed  after  a 
time  and  the  tattooing  will  have  to  be  repeated. 

Ribbon-shaped  opacity  is  a  faint  hazy  opacity 
which  crosses  the  cornea  transversely  in  the  horizontal 
meridian.  It  progresses  very  slowly  and  is  supposedly 
due  to  deposits  of  calcareous  salt  in  the  cornea.  It 
occurs  in  old  people  and  accompanies  other  degenera- 
tive changes  in  the  eye  or  may  be  the  forerunner  of  a 
glaucomatous  condition. 

Lead   deposits   are    dense   white    opacities    which 

result  from  the  use  of  lead  washes  in  the  treatment  of 

FIG.  G7.  eye  affections  when  there  is  corneal  ulceration.     They 

may  be  removed  as  far  as  possible  by  carefully  scraping  them 

off  with  a  knife,  when  the  remaining  opacity  will  gradually 

clear  up. 

Arcus  senilis  is  an  opacity  which  appears  after  middle  life. 
It  is  confined  to  the  margin  of  the  cornea  and  is  due  to  fattj' 
degeneration  of  the   corneal  tissue;  it  occurs  in  the   upper, 


STAPHYLOMA  CORNER— KERATO.CORNUS.  259 

afterwards  in  tlie  lower  portion,  and  then  encircles  tlie  cornea. 
There  is  a  transparent  portion  between  the  opacity  and  the 
corneal  margin. 

Staphyloma  Corner  (Plate  III,  Fig.  4)  is  a  protrusion  of 
the  cornea  caused  by  the  pressure  of  the  intra-ocular  fluids 
during  the  process  of  healing  which  follows  suppurative 
inflammation  of  the  cornea  while  the  tissue  is  soft  and  yielding, 
and  occurs  more  frequently  in  children.  It  may  be  prevented, 
to  some  extent,  by  the  use  of  Calc.  phos.  internally  and  the 
frequent  puncture  of  the  protruded  portion,  thus  lessening  the 
tension,  until  the  cicatricial  tissue  has  become  more  resistant. 
A  large  iridectomy  may  prove  beneficial  in  arresting  the 
staphyloma.  "When  it  has  become  total  the  vision  is  lost  and 
the  choice  lies  between  the  removal  of  the  whole  eyeball  or  its 
anterior  part  only,  and  removal  of  the  contents  of  the  eye. 
The  latter  operation  leaves  a  better  stump  for  an  artificial  eye, 
and  the  danger  of  any  sympathetic  trouble  is  not  very  great  in. 
this  case. 

The  operation  for  evacuation  of  the  eyeball  is  made  in  the 
following  manner:  The  patient  is  put  under  the  influence  of 
ether  and  the  eyelids  separated  by  a  speculum.  The  ciliary 
region  is  then  transfixed  by  a  Beers  knife  held  parallel  to  the 
front  of  the  eye  and  the  anterior  portion  completely  removed; 
the  interior  structures  are  then  entirely  removed  by  mping 
them  out  with  small  balls  of  charpie  which  are  held  by  forceps, 
until  nothing  remains  but  the  scleral  envelope.  The  conjunc- 
tiva at  the  outer  anterior  margin  of  the  sclera  may  be  brought 
together  by  two  cross  sutures  and  a  light  dressing  applied. 
The  reaction  is  apt  to  be  great  in  some  cases  and  may  be 
prevented  by  the  use  of  ice  compresses  for  twenty-four  hours. 
The  stump  is  in  a  condition  to  wear  an  eye  in  about  a  month, 
after  the  operation. 

Kerato  Cornus  or  Conical  Cornea  (Fig.  98)  is  a  conical 
protrusion  of  the  cornea  due  to  atrophy  of  the  elements  of  the 
true  corneal  tissue,  thus  lessening  the  resistant  power  of  this 
membrane. 

The  change  comes  on  insidiously,  the  patient  finding  his 


260  DISEASES  AND  INJURIES  OF  THE  EYE. 

vision  less  distinct  yet  experiencing  no  pain,  nor  is  there  any 
particular  injection.  The  increased  convexity  of  the  cornea 
may  be  scarcely  noticeable,  but  as  the  disease  progresses  the 
apex  of  the  cornea  projects  between  the  lids,  and  being  na 
longer  protected,  becomes  rough  and  finally  opaque.      The= 

protrusion  may  cease,  however,  at. 
any  stage,  and  scarcely  ever  ruptures^ 
as  the  corneal  tissue  becomes  so  thin, 
at  the  apex  that  the  aqueous  filters- 
through.  It  occurs  usually  between 
fifteen  and  twenty  years  of  age  and 
in  delicate  individuals.  Both  eyes 
are  affected  generally,  but  in  dif- 
FiG.  98.  ferent  degrees.     The  vision  is  very 

greatly  diminished  owing  to  the  abnormal  curvatures  and 
from  the  elongation  of  the  axis  of  the  eyeball,  and  there  is- 
slight  improvement  from  concave  glasses. 

The  diagnosis  is  easily  made  if  the  disease  has  progressed 
to  any  extent,  as  the  conical  shape  of  the  cornea  is  easily  seen 
when  viewed  in  profile.  All  cases  of  rapidly  progressing 
myopia  with  amblyopia  should  be  carefully  examined  to  deter- 
mine whether  it  is  due  to  the  conical  projection  of  the  cornea. 
Treatment — Moderate  degrees  may  be  much  benefited  by 
the  internal  administration  of  Calc.  iod.  and  Cannabis,  and  the 
constant  instillation  of  atropine,  together  with  the  use  of  a. 
pressure  bandage  when  the  disease  is  in  a  progressive  stage. 
If  the  progress  is  extremely  slow,  or  has  ceased,  a  careful 
study  of  the  refraction  and  the  use  of  combined  cylindrical 
and  spherical  lenses  may  improve  the  vision.  Lately  it  has 
been  proposed  to  grind  lenses  with  such  parabolic  curves  as- 
should  give  the  best  results  in  improving  the  vision.  In 
extreme  cases  Von  Graefe's  operaiion  may  prove  useful.  Thia 
consists  in  shaving  off  the  apex  of  the  cornea  until  half  its- 
thickness  is  removed  and  allowing  the  wound  to  heal;  the 
resulting  cicatrix  flattens  the  cornea  somewhat,  and  an  artifi- 
cial pupil  is  then  made  by  an  iridectomy  and  the  central  scar 
tattooed. 


TUMORS  OF  THE  CORNEA.  261 

The  operation  of  Bowman  consists  in  trephining  the  cornea 
"with  a  small  trephine  which  removes  a  circular  disc  from  its 
■centre  and  the  wound  treated  in  the  same  way  as  in  Graefe's 
operation. 

Kerato-globus  is  a  general  enlargement  of  the  whole 
<;ornea  and  is  a  congenital  condition,  or  may  result  from  severe 
cases  of  pannus  or  vascular  keratitis,  which  produces  a  soft- 
ening of  the  corneal  tissue  which  allows  of  its  distention. 

Treaiment — Little  can  be  done  to  improve  the  condition  of 
the  patient  beyond  the  application  of  a  pressure  bandage. 
The  removal  of  a  large  section  of  the  iris  may  be  beneficial. 

TUMORS  OF  THE  CORNEA. 

Tumors  of  the  cornea  occur  very  rarely.  They  are  com- 
monly dermoid  tumors  which  arise  from  the  corneal  margin 
and  involve  both  the  cornea  and  sclera  and  are  usually  congen- 
ital. They  are  white  or  brown  in  color  and  small  in  size  and 
may  present  hairs.     They  are  readily  removed  by  the  knife. 

Epithelioma  is  a  very  rare  affection  and  appears  also  at  the 
corneal  margin.  Dr.  T.  F.  Allen  reports  a  case  where  the 
^roAvth  encircled  the  cornea  which  cleared  up  very  markedly 
Tinder  the  use  of  Hepar  s.  and  Calc.  carb. 

Melanoma  and  Sarcoma  may  appear  at .  the  corneal  border 
and  should  be  thoroughly  removed  as  soon  as  possible. 


CHAPTER  XIL 

DISEASES    OF    THE    SCLERA. 

ANATOMY. 

The  sclera,  or  sclerotic  coat  of  the  eye,  is  a  strong,  opaque, 
tinyiekling,  fibrous  structure,  the  outer  surface  being  white 
and  smooth  except  where  the  tendons  of  the  ocular  musclea 
are  inserted.  It  is  thinnest  anteriorly  about  one-fourth  of  an 
inch  from  the  cornea  and  thickest  at  the  posterior  portion 
where  the  sheaths  of  the  optic  nerve  unite  with  it.  The  optic 
nerve  pierces  the  sclera  about  one-tenth  of  an  inch  to  the 
inner  side  of  the  axis  of  the  eyeball,  and  the  opening  is  some- 
what smaller  at  the  inner  than  at  the  outer  surface  of  the  coat. 

The  sclera  consists  of  connective  tissue  fibres  combined  with 
fine  elastic  tissue,  and  amongst  these  lie  connective  tissue 
corpuscles  lodged  in  cell  spaces,  similar  to  but  not  as  regularly 
arranged  as  those  in  the  cornea.  The  fibre  bundles  are 
disposed  in  layers  both  longitudinally  and  circularly,  the 
longitudinal  arrangement  being  most  marked  on  the  surface. 
These  layers  interlace  and  form  a  dense  meshwork. 

A  few  blood-vessels,  in  the  form  of  capillaries  with  wide 
meshes,  are  distributed  through  its  texture.  Upon  the  surface 
of  the  sclerotic  near  the  cornea,  when  this  region  is  congested, 
are  seen  a  number  of  vessels  which  are  derived  from  the 
muscular  and  anterior,  ciliary  arteries ;  they  are  not  movable  as 
are  the  overlying  vessels  of  the  conjunctiva.  These  sclerotic 
Tessels  dip  in  near  the   cornea    and    appear  to  unite  with  a 

262 


DISEASES  OF  THE  SCLERA— SCLERITIS.  263 

deeper  capillary  network  disposed  in  closely  set  lines  wliich 
radiate  from  the  margin  of  the  cornea,  and  are  visible  when 
the  sclera  becomes  inflamed.  At  the  anterior  edge  of  the 
inner  surface  of  the  sclera  a  circular  canal,  the  canal  of 
Schlemm,  lined  by  endothelial  cells,  gives  passage  to  various 
plexuses  of  vessels  from  the  sclera,  and  the  ciliary  veins,  which 
communicate  with  the  anterior  chamber  and  the  anterior  ciliary 
veins. 

In  its  anterior  portion  the  sclera  gives  passage  to  the 
anterior  ciliary  arteries,  veins  and  nerves;  at  the  equator  to 
the  venae  vorticosae  from  the  choroid,  and  more  posteriorly  to 
the  posterior  ciliary  arteries  and  nerves. 

The  sclerotic  derives  its  blood  supply  from  the  anterior 
ciliary  system  and  from  the  arteries  about  the  optic  nerve 
entrance  which  form  a  posterior  vascular  zone. 

The  presence  of  nerves  in  the  sclera  has  not  been  satisfac- 
torily demonstrated. 

The  inner  surface  of  the  sclera  is  grooved  for  the  passage  of 
the  ciliary  arteries  and  nerves  and  is  brownish  from  the  pres- 
ence of  pigment  cells,  and  is  closely  connected  to  the  choroid 
and  ciliary  body  by  the  lamina  fusca,  the  loose  trabecular 
tissue  over  which  are  disposed  endothelial  cells  and  which 
forms  the  lymph  space  existing  between  the  sclera  and  the 
choroid.  The  outer  surface  is  somewhat  rough  and  connected 
by  loose  connective  tissue  to  the  slieath  of  the  globe,  tunica 
vaginalis  or  Tenon's  capsule,  and  anteriorly  is  connected  to 
the  conjunctiva  by  shorter  filaments  of  subconjunctival  tissue. 

DISEASES  OF  THE  SCLERA 

The  sclera,  owing  to  its  very  moderate  blood  supply  and 
almost  total  absence  of  nerves  is  rarely  the  seat  of  acute 
inflammatory  action,  except  from  extension  of  diseased  condi- 
tions of  the  cornea,  iris,  ciliary  body  and  choroid.  In  the 
normal  condition,  the  sclera  appears  of  a  bluish  white  color 
upon  which  are  seen  the  blood-vessels  of  the  overlying  conjunc- 
tiva, at  its  anterior  portion  an  anastomosing  ring  of  vessels,  the 


264 


DISEASES  AND  INJURIES  OF  THE  EYE. 


scleral  or  ciliary  zone,  becomes  apparent  upon  any  inflamuia- 
tory  affection  of  the  cornea,  iris  or  ciliary  body  and  constitutes 
an  hyperaemia  of  the  sclera.  Inflammation  of  the  sclera  is 
characterized  by  the  formation  of  new  blood-vessels  and  infiltra- 
tion of  cells,  which  may  result  in  thickening,  or  lead  to 
softening  with  thinning  and  distention  of  its  tissue. 

SCLERITIS. 

Inflammation  of  the  sclera  presents  a  dusky  crescent  of  con- 
gested vessels  usually  upon  the  outer  side  of  the  cornea,  or 
purplish  spots  appear  upon  the  anterior  portions  of  the  sclera, 
more  frequently  about  the  insertion  of  the  recti  muscles  where 
we  have  a  greater  blood  supply.  There  is  swelling  of  the 
portions  of  the  sclera  affected,  with  dull  pain,  lachrymation, 
and  fatigue  on  use  of  the  eyes.  The  margin  of  the  cornea  may 
be  invaded  and  the  sclero-corneal  junction  appears  irregular 
and  new  tissue  formations  occur  in  the  cornea.  The  inflamma- 
tion is  of  a  low  type,  and  if  it  does  not  appear  in  the  ciliary 
region,  gradually  extends  to  it,  and  involves  the  cornea 

Causes. — It  is  more  commonly  seen  in  women  and  appears 
to  be  connected  with  uterine  irritation,  suppressed  menstrua- 
tion and  cessation  of  uterine  functions.  In  men  it  is  often 
associated  with  a  rheumatic  or  gouty  diathesis.  In  young 
people  it  seems  to  be  dependent  vipon  malarious  causes.  Some 
cases  may  be  traced  to  a  syphilitic  taint,  and  a  small  gummy 
tumor  may  make  its  appearance  in  the  sclera. 

Symptoms. — Beyond  the  dusky  appearance  of  the  sclera  at 
the  point  affected,  the  dull  pain,  and  the  absence  of  any  dis- 
charge, there  is  little  to  call  attention  to  the  disease,  as  the 
vision  is  very  rarely  affected,  and  when  the  latter  is  disturbed, 
it  arises  from  the  extension  of  the  inflammation  to  (he  choroid. 

Prognosis. — The  progress  of  scleritis  is  usually  very  slow, 
often  lasting  for  months,  and  if  the  inflammatory  process 
involves  but  a  small  portion  of  the  sclera,  the  natural  tendency 
of  the  affection  is  toward  recovery.  If  the  inflammation  is 
extensive,  or  situated  near  the  corneal  margin,  the  sclera  may 


SCLERTTIS— EPISCLERITIS.  265 

Tjulge  forward  changing  the  relation  of  the  interior  struct- 
ures and  thus  injure  the  vision,  or,  as  is  not  infrequently  the 
case,  the  choroid  or  ciliary  body  become  involved  in  the 
inflammatory  process  and  the  danger  to  the  eye  is  thereby 
increased.  Again,  the  cornea  may  suffer  from  ulceration,  or 
opaque  tissue  be  formed  in  its  structure  and  encroach  upon 
the  pupil  and  thus  interfere  with  the  vision. 

The  disease  shows  a  strong  tendency  to  recur  and  the 
softened  sclera  yields  to  the  intra-ocular  pressure  and  staphy- 
loma results.  Occasionally  there  is  a  marked  increase  of  the 
intra-ocular  tension  which  may  necessitate  operative  measures. 

Treatment. — The  local  symptoms  are  very  meagre  and  the 
general  symptoms  of  the  patient  must  be  carefully  considered 
in  making  our  prescription.  No  local  applications  are  admis- 
sible excepting  the  use  of  atropine,  when  the  cornea  or  iris 
become  involved.  Among  the  internal  remedies  which  may 
be  called  for  in  this  disease  are  Ars,,  Merc,  prot.,  Aurum  mur., 
Thuja,  Kux  moscli.,  Silicia  and  Kalmia  lat,  in  the  order  given. 
If  there  is  much  increase  of  tension  an  iridectomy  may  be 
necessary. 

Episcleritis  is  a  term  which  formerly  included  all  the 
forms  of  scleral  inflammation,  but  should  be  confined  to  those 
partial  inflammatory  affections  of  the  episcleral  tissue  which 
present  appearances  similar  to  scleritis.  The  tissue  of  the 
conjunctiva  over  the  inflamed  portion  is  hyperremic,  but  there 
is  no  conjunctival  discharge.  The  pain  is  often  more  severe 
than  in  scleritis,  and  the  disease  will  exhibit  the  same  tendency 
to  recurrence,  but  is  not  as  obstinate,  and  the  attacks  are 
much  shorter. 

Causes. — The  cause  is  rarely  determinable,  but  the  con- 
dition occurs  in  rheumatic  and  gouty  cases  more  frequently 
than  in  others. 

Treatment — In  addition  to  the  remedies  noted  for  scleritis, 
Terebinth,  Sulph.  and  Puis,  may  be  indicated. 

Sclerotico-Choroiditis  Anterior  or  anterior  staphyloma 
of  the  sclera  may  arise  by  the  extension  of  the  inflammatory 
softening  or  atrophic  process  of  the  cornea,  or  as  the  result  of 


266 


DISEASES  AND  INJURIES  OF  THE  EYE. 


choroiditis,  scleritis,  or  iutra-ocular  tumors.  The  thinnest 
•  part  becomes  prominent  and  bluish  and  the  internal  parts  of 
the  eye  are  usually  distended  and  atrophied.  It  may  be  partial 
or  total.  When  the  whole  anterior  portion  of  the  eye  is 
involved,  the  disease  is  called  BiipMhalmus;  if  the  whole  eye- 
ball is  affected  it  is  called  Hydrophthalmus. 

The  vision  is  usually  lost  from  the  implication  of  the  nerve 
structures,  and  enucleation  is  often  advisable.  The  condition 
may  lead  to  a  glaucomatous  degeneration,  or  sympathetic 
inflammation  of  the  other  eye. 

Causes. — Anterior  staphyloma  of  the  sclera  may  arise  from 
an  iritis  which  has  involved  the  angle  of  the  iris  and  the  canal 
of  Schlemm,  or  from  irido-cyclitis,  or  incised  wounds  in  the 
ciliary  region. 

Symptoms  and  Diagnosis. — The  bulging  of  the  sclera,  in 
whole  or  in  part,  is  unmistakable  when  present. 

Treatment — Nothing  can  be  done  for  the  condition  when  it 
has  become  once  established,  except  to  remove  the  eyeball  if 
it  becomes  a  source  of  irritation  to  the  other,  or  when  the 
projection  of  the  sclera  is  such  as  to  require  relief  for 
cosmetic  purposes.  Here  enucleation  will  be  necessary, 
unless  the  whole  eyeball  is  involved,  when  evacuation  of  the 
contents  of  the  globe  as  described  under  staphyloma  corneae 
will  be  better,  as  the  great  enlargement  of  the  globe  results 
in  the  absorption  of  the  contents  of  the  orbit  to  a  considerable 
extent,  and  the  removal  of  the  whole  eye  under  these  circum- 
stances does  not  leave  sufficient  cushion  for  an  artificial  eye  to 
make  it  sufficiently  prominent  for  cosmetic  purposes. 

Scleeotico-Choeoiditis  Posteeige,  or  posterior  staphy- 
loma of  the  globe  is  much  more  frequent  than  that  just 
described  and  is  the  productive  cause  of  many  cases  of  myopia. 
It  usually  occurs  at  the  posterior  pole  on  the  temporal  side  of 
the  optic  nerve,  and,  with  the  ophthalmoscope,  appears  as  a 
perfectly  white  spot  from  which  the  choroid  has  been 
retracted,  and  appears  either  as  a  crescent,  or  later,  involves 
the  whole  of  the  sclera  about  the  optic  nerve  entrance  and 
forms  an  irregular  ring. 


SCLEROTICO-CHOROIDITIS  POSTERIOR— TREATMENT.        267 

Treatment. — The  treatment  consists  in  the  use  of  those 
remedies  which  have  already  been  considered  when  speaking 
of  the  secondary  disturbance  of  myopia  and  the  use  of  such 
hygienic  measures  as  have  been  indicated  in  cases  of  pro- 
gressive myopia. 


CHAPTER    XIIL 

DISEASES    OF    THE    IRIS. 

ANATOMY. 

Tlie  iris  is  the  contractile  and  colored  membrane  whicli  is 
seen  behind  the  cornea  and  which  gives  the  tint  to  the  eye. 
In  the  centre  of  this  movable  curtain  is  a  circular  aperture, 
the  pupil.  The  pupil  is  nearly  circular  in  form  and  is  placed 
■a.  little  to  the  nasal  side  of  the  centre  of  the  iris.  It  varies  in 
size  according  to  the  contraction  or  relaxation  of  its  muscular 
fibres,  this  variation  ranging  from  ^V  to  ^  of  an  inch,  and 
regulates  the  amount  of  light  admitted  to  the  eyeball.  The 
membrane  of  Decemet,  on  reaching  the  angle  of  the  iris,  t.  e. 
the  space  in  the  anterior  chamber  bounded  by  the  posterior 
margin  of  the  cornea  and  the  anterior  surface  of  the  iris, 
l)reaks  up  into  fibrillse  of  connective  tissue,  and  these  extend 
through  half  the  breadth  of  the  iris  forming  the  ligamenhim 
pectinatum  iridis,  or  the  supporting  ligament  of  the  iris.  The 
endothelial  cells  of  the  posterior  surface  of  the  cornea  are 
continued  upon  the  trabeculated  tissue  at  the  angle  of  the  iris 
and  pass  forward,  becoming  smaller  and  more  granular,  upon 
the  anterior  surface  of  the  iris  itself.  The  anterior  surface  of 
the  iris  presents  numerous  furrows  which  take  a  radial  direc- 
tion, except  near  the  pupillary  margin  where  they  become 
circular.  The  tint  of  the  iris  results  from  an  interference 
phenomenon  of  light,  caused  by  its  broken  anterior  surface, 
and  from  the  brown  pigment  cells,  which  in  dark  eyes    are 


DISEASES  OF  THE  IRIS. 


26^ 


imbedded  in  the  tissue  of  the  iris.  At  its  circumference  we 
have  the  iris  continuous  with  the  ciliary  body  and  choroid, 
the  posterior  surface  being  covered  by  a  layer  of  dark  pigment 
cells  which  is  continuous  with  the  uvea,  the  retinal  layer  of 
pigment  which  also  covers  the  choroid  and  ciliary  body. 
Between  these  two  layers  of  cells,  the  epithelial  anterior  layer 
and  the  layer  of  pigment  cells,  just  described,  is  the  stroma  of 
the  iris,  which  consists  of  loose  fibres  of  connective  tissue, 
having  a  radial  course  towards  the  pupil,  and  a  circular  one  at. 
the  circumference.     These  interweave  with  one  another  until  a. 

loose  web  is  formed,  which 
gives  support  to  the  pig- 
ment cells,  which  are 
branching  and  contain 
brown  or  yellow  pigment. 
In  this  stroma  we  find  the 
muscles,  blood-vessels  and 
nerves. 

The  muscular  fibres  are 
arranged  in  plates  and  are 
of  the  involuntary  variety ;, 
one  plate  is  disposed 
around  the  pupil  (a  Fig. 
riG-9»-  Q9)    and    is    termed    the 

sphincter,  the  other  (6  Fig.  99)  appears  as  rays  which  come 
from  the  circumference  and  run  towards  the  pupil.  The 
sphincter  muscle  is  a  narrow,  flat  band  of  muscular  fibres  -^^ 
of  an  inch  wide,  on  the  posterior  surface  of  the  iris  close  to 
the  pupilary  margin.  It  is  supplied  by  a  branch  of  the  third 
nerve.  The  dilator  of  the  iris,  the  existence  of  which  has 
been  doubted,  is  a  very  thin  layer  of  muscular  fibres  on  the 
posterior  surface  of  the  iris  stroma,  covered  and  permeated 
by  pigment  cells.  These  radial  fibres  do  not  form  a  contin- 
uous muscle,  but  extend  from  the  ciliary  body  in  minute 
fascicles,  which,  as  they  approach  the  sphincter  unite,  forming 
arched  plexuses  which  are  partially  lost  in  the  sphincter. 
Vessels  and  Nerves  of  the  Iris. — The  long  ciliary  arteries. 


270  DISEASES  AND  INJURIES  OF  THE  EYE. 

two  in  number,  pierce  the  sclerotic  a  little  in  front  and  on  each 
side  of  the  optic  nerve,  and  run  through  the  loose  tissue 
between  the  sclera  and  choroid  directly  forward  to  the  ciliary- 
muscle  a  short  space  behind  the  fixed  margin  of  the  iris. 
These  vessels  branch  above  and  below  and  form  a  circular 
ring  of  arterial  supply,  which  is  augmented  by  the  anterior 
ciliary  arteries  which  branch  from  the  arteries  of  the  recti 
muscles.  These  anastomosing  form  the  arterial  ring,  or 
circulus  major,  from  which  small  branches  supply  the  muscles 
•whilst  others  converge  towards  the  pupil  and  when  near  the 
margin,  form  another  anastomosing  circle,  the  circulus  minor, 
from  which  capillaries  are  continued  inward  and  end  in  small 
veins,  which,  increasing  in  size,  follow  the  arrangement  of  the 
arteries  and  pass  into  the  canal  of  Schlemm. 

The  nerves  of  the  iris  are  derived  from  the  ciliary  nerve, 
ivhich  follows  nearly  the  course  of  the  blood-vessels,  dividing 
into  branches  which  communicate  with  one  another  as  far  as 
the  pupil,  there  forming  a  close  plexus  of  non-meduUated 
fibres,  whose  ultimate  termination  is  not  known. 

DISEASES  OF  THE  IKIS. 

Inflammatory  diseases  of  the  iris  are  very  common  and 
present  several  forms  according  to  the  nature  of  the  inflam- 
matory product,  and  are  the  frequent  accompaniments  of  acute 
or  chronic  diseases  affecting  the  conjunctiva,  cornea,  ciliary 
l)ody  and  choroid. 

IRITIS. 

Inflammation  of  the  Iris,  or  Iritis  (Plate  IV,  Fig.  1),  is 
characterized  by  an  engorgement  of  the  vessels,  the  exudation 
of  serum  into  its  tissue  causing  a  swollen,  spongy  condition ; 
the  stroma  cells  become  enlarged  and  their  contents  turbid, 
proliferation  occurs  and  neoplastic  growths  result.  Again, 
the  product  of  the  inflammatory  action  may  be  more  plastic  or 
lymph-like,  the  tissues  become  more  swollen  and  stiff  and  the 


PLATE  IV 


Iribis 


Iritis/rregular  pupil 


^'Wfft^fv^ 


Syphilitic  I rihsf  Condyloma) 


Irido-Choroiditis 


IRITIS— SYMPTOMS.  271 

exudation  collects  upon  the  surface  or  fills  the  pupillary  space 
with  a  membranous  formation;  or,  it  may  consist  entirely  of 
pus  cells,  which  are  found  to  extend  through  the  iris  tissue 
and  destroy  it,  or  appear  upon  the  surface  of  the  iris  or  collect 
in  the  anterior  chamber,  forming  an  hypopyon.  While  all 
these  pathological  features  may  be  present  during  any  attack 
of  iritis,  yet  in  the  inflammatory  diseases  of  the  iris  each  case 
presents  a  more  or  less  well-defined  form  of  exudation.  Clini- 
cally, there  is  no  special  distinctive  feature  of  the  inflammatory 
process  which  enables  us  to  determine  the  cause.  It  will  be 
better  then  to  divide  the  various  forms  according  to  their 
pathology  into  serous,  plastic,  and  suppurative  varieties. 

Causes. — Iritis  may  occur  at  any  age  and  from  a  great 
variety  of  causes.  It  appears  more  commonly  between  the 
ages  of  twenty  to  fifty  years,  and  more  frequently  in  men  than 
women  and  generally  one  eye  is  affected,  or  one  eye  is  attacked, 
and  disease  of  the  other  follows.  Recurrent  attacks  are  not 
uncommon.  The  most  frequent  cause  being  syphilis,  inherited 
or  acquired;  when  occurring  in  very  young  children,  it  is 
often  indicative  of  inherited  syphilitic  taint.  It  may  precede 
<^  accompany  secondary  symptoms  of  acquired  syphilis,  being 
more  commonly  observed  during  the  eruption  of  the  roseola, 
or  it  may  appear  months  or  years  after  the  primary  disease. 
Injuries  and  operations  upon  the  iris,  or  eyeball,  and  diseases 
of  the  cornea  and  conjunctiva,  form  the  next  most  frequent 
causes.  It  frequently  occurs  idiopathically  from  sudden 
changes  of  the  weather,  exposure  to  wet  or  cold,  particularly 
in  ill-nourished  and  feeble  persons,  or  in  those  exhibiting  a 
rheumatic  diathesis,  and  in  patients  suffering  from  gonorrhoea 
with,  or  without,  gonorrhceal  rheumatism.  It  may  appear  in 
young  girls  at  puberty,  or  result  from  suppression  of  the 
menses.  Finally,  it  forms  a  very  important  part  of  the  dread 
disease,  known  as  sympathetic  ophthalmia. 

Symptoms. — The  surface  of  the  iris  loses  its  lustre  and 
striated  appearance,  and  its  color  becomes  dull  and  changed 
from  the  congestion  and  effusion  into  its  structures,  together 
with  the  turbid  condition  of  the  aqueous  which  occurs  from 


272  DISEASES  AND  INJURIES  OF  THE  EYE. 

the  exudation.  The  iris  does  not  respond  promptly  to  the 
stimulus  of  light,  owing  to  the  increase  in  its  volume;  it  may- 
be immovable  from  the  gluing  of  its  posterior  surface  to  the 
lens  from  the  plastic  nature  of  the  exudation.  The  pupil 
appears  dull  and  in  many  cases  is  contracted  or  filled  with 
lym2)h.  If  the  attack  is  severe  a  large  quantity  of  lymph  is 
thrown  out  and  collects  upon  the  pupillary  margin  in  minute 
beads  or  covers  the  surface  of  the  iris,  or  extends  across  the 
pupillary  opening.  The  eyeball  is  congested,  particularly  in 
what  is  termed  the  ciliary  zone,  that  portion  of  the  sclera 
immediately  behind  the  cornea,  where  a  zone  about  one-fifth  of 
an  inch  wide  exhibits  a  pinkish  injected  appearance  due  to  the 
development  of  straight  radiating  vessels,  branches  of  the 
anterior  ciliary  arteries,  which  appear  larger  at  the  corneal 
margin  and  disappear  after  extending  a  short  distance  upon 
the  sclera.  This  condition  is,  however,  masked  by  the  conges- 
tion of  the  overlying  conjunctiva.  Owing  to  the  great  vascu- 
larity of  the  iris  and  its  plentiful  supply  of  sensitive  nerves, 
its  inflammation  is  very  marked  and  accompanied  by  severe 
pain  due  to  pressure  of  the  nerve  filaments  by  the  exudation. 
The  pain  is  not  limited  to  the  eye,  but  extends  over  the  supra- 
orbital region  and  to  the  sensitive  fibres  of  the  fifth  nerve,  and 
is  variable  and  neuralgic  in  character,  worse  at  night  and  after 
midnight.  There  is  usually  great  intolerance  of  light,  but 
this  is  a  variable  symptom  and  not  as  constant  as  in  corneal 
affections.  Lachrymation  is  often  copious,  but  there  is  no 
discharge  of  mucus  or  pus  as  in  conjunctival  diseases.  The 
vision  is  misty  or  is  much  diminished  from  the  aqueous 
becoming  turbid  from  the  exudation  mixing  with  it,  or  from 
the  pupil  becoming  occluded  with  lymph.  The  tension  of  the 
eyeball  is  often  slightly  increased.  There  may  be  consider- 
able febrile  disturbance  and  a  rise  of  one  or  two  degrees  in  the 
temperature.  There  may  be  also  a  swollen  oedematous  condi- 
tion of  the  lids,  this  being  more  fiequently  the  accompaniment 
of  iritis  following  operations  upon  the  eye,  as  after  cataract 
extraction  when  it  is  an  early  indication  of  the  commencing 
inflammation.     In  the  acute  forms  of  iritis,  all  these  symptoms 


IRITIS— DIAGNOSIS— COMPLICA  TIONS.  273 

are  very  prominent,  but  in  the  more  clirouic  varieties  there  is 
great  variation;  the  impaired  vision  with  discoloration  of  the 
iris  and  the  presence  of  adhesions  between  the  lens,  and  the 
iris,  may  be  the  only  symptoms  present. 

Diagnosis. — From  the  symptoms  thus  fully  given,  there 
should  be  little  difficulty  in  recognizing  the  disease.  The  con- 
dition of  the  pupil  as  to  color  and  mobility,  when  compared 
with  the  well  eye,  is  more  diagnostic  than  the  other  symptoms, 
and  the  use  of  atropine  causes  a  dilatation  of  the  parts  of  the 
iris  between  the  adhesions,  or  synechia,  giving  the  pupil  an 
irregular  appearance  (Plate  IV,  Fig.  2)  when  present,  and  is 
conclusive  evidence  of  iritis,  and  enables  a  correct  diagnosis 
to  be  made.  In  cases  of  iritis  where  the  aqueous  is  cloudy 
the  use  of  atropine  clears  up  the  anterior  chamber,  and  gives 
a  view  of  the  iris  while  in  keratitis  when  the  cornea  is  hazy 
the  condition  is  not  changed. 

In  the  early  stages  of  iritis,  or  when  the  hyperemia  has 
involved  the  vessels  of  the  conjunctiva,  the  diagnosis  may  be 
difficult,  but  the  presence  of  marked  pain  and  a  sluggish  con- 
dition of  the  pupil  in  iritis  and  the  absence  of  the  discharge 
and  of  severe  pain,  which  is  present  in  conjunctival  affections, 
will  generally  be  sufficient  to  differentiate  between  the  two  dis- 
eases, and  in  all  cases  of  doubt,  atropine  should  be  used,  and 
if  there  are  any  synechise,  they  will  become  observable  at  once. 
From  neuralgic  affections  of  the  ciliary  nerves,  it  will  be  differ- 
entiated by  an  absence  of  pain  and  inllammation  presemfc  in  the 
purely  neuralgic  affection ;  from  cyclitis  which  may  complicate 
the  attack,  it  may  be  diagnosticated  by  the  pain  being  more 
severe  and  the  extreme  sensitiveness  of  the  ciliary  region  to 
touch  in  cyclitis. 

Complications  and  Sequels. — From  the  similarity  of  the 
structure  and  the  common  vascular  supply  of  the  iris,  ciliary 
body  and  choroid,  inflammation  of  the  iris  tends  to  involve 
these  tissues.  Diseases  of  the  cornea  or  sclera  often  impli- 
cate the  iris  and  thus  render  the  situation  more  grave.  The 
permanent  results  of  iritis  are  adhesions  to  the  lens  capsule, 
or  posterior  synechise,  and  occlusion  of  the  pupil  by  means  of 

18 


274  DISEASES  AND  INJURIES  OF  THE  EYE. 

organized  exudation;  the  adhesions  of  the  iris  to  the  lens 
capsule  may  be  slight,  or  extend  over  a  greater  portion  of  the 
surface,  and  thus  interfere  with  the  nutrition  of  the  lens,  and 
cause  cataract.  Defective  sight  is  occasioned  by  these  changes 
in  the  pupil  or  in  the  lens,  and  also  by  plastic  exudation  and 
pigment  spots,  which  may  be  left  on  the  capsule  from  the 
synechise,  and  if  occurring  in  the  pupil,  or  near  its  margin, 
cause  the  appearance  of  black  spots  in  the  visual  field  which 
prove  very  annoying  to  the  patient. 

Prognosis. — If  early  recognized  and  properly  treated  the 
result  is  almost  always  favorable.  The  attack  may  be  so  slight 
as  to  disappear  in  a  few  days,  yet  if  neglected  or  improperly 
treated  may  rapidly  destroy  the  eye,  or  continue  for  months 
and  end  in  atrophy  of  the  iris  tissue,  or  of  the  whole  eyeball. 
Mild  cases  usually  last  for  two  or  three  weeks,  but  the  duration 
depends  more  upon  the  severity  of  the  attack  and  its  methodi- 
cal treatment. 

Treatment. — In  every  case  of  iritis,  and  whatever  the  cause 
may  be,  the  first  thing  to  be  done  is  to  use  atropine  to  dilate 
the  pupil,  because  it  relieves  the  tension  of  the  eyeball,  pre- 
vents adhesions  forming  between  the  iris  and  the  lens,  or 
between  the  opposite  margins  of  the  pupil,  which  might  other- 
wise become  entirely  blocked  up  with  lymph.  It  also  gives 
rest  to  the  inflamed  tissue  and  has  a  marked  efiect,  in 
most  cases,  upon  the  severity  of  the  pain.  A  drop  of  a  four- 
grain  solution  of  atropine  is  to  be  placed  inside  the  lower  lid, 
every  half  hour,  until  the  whole  iris,  or  such  portions  of  it  as 
are  not  bound  down  by  adhesions,  is  fully  dilated.  Afterward 
a  drop  every  two  or  three  hours,  or  less,  will  be  sufiicient  to 
keep  up  the  impression  made.  If  the  pupil  dilates  fully  and 
the  atropine  is  kept  up  until  all  congestion  has  disappeared, 
the  eye  will  recover  without  other  treatment.  If  the  adhesions 
of  the  iris  are  recent  and  not  very  extensive,  the  atropine  will 
often  tear  them  so  that  the  pupil  will  again  become  regular, 
and  further  adhesions  be  prevented  by  keeping  the  pupil  w^ell 
dilated.  If  atropine  is  not  well  borne,  which  fortunately  is 
rare,  greater  care  must   be  exercised   in  instilling  it  into  the 


IRITIS—TREATMENT— REMEDIES.  275 

eye,  and  if  much  irritation  or  pain  follows  its  use,  or  toxic 
effects  appear,  some  other  mydriatic,  as  duboisia,  should  be 
substituted.  Homatropine  is  comparatively  valueless  in  the 
treatment  of  inflammatory  diseases  of  the  iris. 

All  use  of  the  eyes  for  near  work  must  be  forbidden,  and  the 
case  will  recover  more  quickly  if  confined  to  the  house  and,  in 
severe  cases,  to  the  bed,  where  an  equal  temperature  can  be 
sustained,  as  all  cases  of  iritis  are  quickly  affected  by  changes 
in  temperature  or  atmospheric  influences.  The  eyes  should  be 
shaded  from  the  light  by  darkening  the  chamber,  or  if  the 
patient  is  allowed  to  be  up  and  out,  dark  protective  glasses  or 
a  shade,  such  as  will  fully  protect  the  eyes,  are  to  be  worn.  A 
bandage  is  rarely  necessary.  The  diet  will  vary  with  the  con- 
dition of  the  patient  and  is  usually  low,  and  all  stimulants 
should  be  interdicted. 

The  pain,  which  is  often  very  severe  and  prevents  sleep, 
interferes  with  recovery  and  may  be  moderated  by  enveloping 
the  afiected  side,  or  the  whole  head,  in  a  layer  of  cotton  batting 
secured  by  a  nightcap  or  bandage.  The  attacks  of  pain  which 
commonly  occur  during  the  night,  demand  the  application  of 
hot  compresses,  either  of  bags  of  hot  bran  or  salt,  or  of  flannels 
wet  with  hot  water  until  the  pain  is  modified  or  relieved. 
Where  atropine  seems  to  exert  but  little  effect  on  the  condition, 
and  the  pain  is  not  controlled,  the  continuous  application  of 
flannels  wet  with  a  hot  decoction  of  hops  and  chamomile  flowers 
will  often  have  a  soothing  effect  and  render  the  absorption  of 
the  atropine  or  duboisia  more  speedy.  Cold  applications  are 
rarely  indicated,  except  in  the  first  stage  of  iritis  following 
injuries  or  operations,  when  they  may  be  prophylactic,  but 
after  the  condition  has  become  one  of  active  inflammation,  they 
should  not  be  used.  If  the  disease  assumes  a  chronic  form, 
or  even  if  it  be  acute  and  obstinately  resists  all  treatment,  or 
whenever  there  is  a  marked  increase  of  the  tension  of  the  eye- 
ball, an  iridectomy  should  be  made,  as  this  may  shorten  the 
attack.  The  incision  should  be  made  with  a  keratome,  just 
behind  the  margin  of  the  cornea  and  the  segment  of  the  iris 
removed  close  to  its  outer  attachment.     The  iridectomy  should 


276  DISEASES  AND  INJURIES  OF  THE  EYE. 

be  made  upward,  so  as  to  be  concealed  by  the  upper  lid.  If 
the  adhesion  of  the  iris  to  the  lens  is  complete,  or  the  pupil 
occluded,  the  immediate  performance  of  an  iridectomy  is 
demanded  as  soon  as  the  congestion  has  disappeared;  the 
operation  should  in  this  case  be  made  inward  and  a  little  down- 
ward, unless  the  pupil  is  clear,  when  it  should  be  made  upward. 
In  these  cases,  it  is  often  impossible  to  make  a  clear  cut  in  the 
iris,  owing  to  the  impossibility  of  drawing  the  iris  out,  but  the 
tissue  tears  easily  and  sufficient  can  generally  be  removed  to 
gain  a  fair  pupil.  If  the  operation  is  too  long  deferred,  the 
lens  becomes  cataractous  and  other  changes  in  the  tissues  give 
but  little  chance  of  any  improvement 

REMEDIES. 

Under  the  following  heads  are  indicated  the  remedies  for  the 
various  forms  of  iritis. 

Aconite. — In  the  first  stage  of  an  attack  which  appears  after 
injuries  to  the  iris.  In  other  varieties  arising  from  exposure 
to  cold  in  which  the  inflammation  appears  sthenic  from  the 
inception  of  the  attack. 

Arnica. — Recommended  for  iritis  arising  from  rheumatic 
and  traumatic  causes,  but  it  is  of  doubtful  utility. 

Asafoeiida. — In  the  plastic  variety  occurring  particularly  in. 
females  and  from  acquired  syphilis.  The  pains  are  very  char- 
acteristic and  are  described  as  of  a  throbbing,  beating  or 
burning  character  in  the  eye,  and  above,  or  around  it,  and 
lessened  by  rest  and  pressure,  as  of  the  face  or  side  of  the  head 
in  the  pillow. 

Auriim  mur. — May  be  indicated  in  some  cases  of  iritis, 
occurring  in  syphilitic  subjects  where  the  pains  are  described 
as  seated  deep  in  the  bones  about  the  eye,  and  of  a  tearing,, 
pressing,  character  and  extend  from  above  downward  and  from 
without  inward.      (The  reverse  of  Asafoetida.) 

Belladonna. — The  choice  between  Aconite  and  Belladonna 
becomes  necessary  in  the  early  stages  of  iritis,  and  will  have 
to  be  made  according  to  the  concomitant  symptoms.     Under 


IRITIS— REMEDIES.  277 

Belladonna,  there  is  usually  marked  photophobia  and  contrac- 
tion of  the  pupil. 

Bryonia. — More  useful  in  the  serous  form  of  iritis,  but  is 
also  indicated  in  the  plastic  when  occurring  in  rheumatic 
patients.  There  is  soreness  and  aching  in  the  eyeball  and 
orbit,  and  sharp,  shooting  pains  which  extend  through  the 
head  or  face,  or  pressure  under  the  orbit  as  if  the  eye  would 
be  forced  out  may  be  complained  of.  The  eyeballs  are  often 
sensitive  to  the  touch  and  on  motion. 

China. — Indicated  in  iritis  occurring  in  debilitated  subjects, 
and  with  a  marked  periodicity,  or  when  arising  from  malarious 
causes. 

Clematis. — This  remedy  is  to  be  strongly  recommended  for 
the  various  forms  of  iritis  when  accompanied  by  little  pain 
and  great  sensitiveness  to  cold  air.  It  has  been  claimed  to 
have  a  marked  absorbent  action  upon  the  synechias,  but  I  have 
never  been  able  to  satisfy  myself  of  its  efficacy. 

Gelsemium. — The  most  valuable  remedy  for  the  serous 
variety.  The  special  eye  symptoms  in  this  variety  of  inflam- 
mation are  not  marked. 

Hepar  sulphur. — Serviceable  in  any  variety  of  iritis,  and 
particulary  indicated  in  the  suppurative  form  with  accom- 
panying hypopyon.  The  pains  are  usually  throbbing  and 
intense,  with  great  sensitiveness  of  the  eye  to  touch.  Warm 
applications  seem  particularly  pleasant. 

Kali  iod. — Yery  useful  in  either  the  plastic  or  serous  forms, 
particularly  from  syphilitic  causes. 

Mercurius. — The  value  of  the  various  forms  of  Mercury  in 
the  treatment  of  iritis,  is,  I  believe,  very  much  overestimated, 
although  it  has  long  been  considered  purely  homoeopathic. 
As  a  result  of  my  own  observations,  I  cannot  agree  with  the 
homoeopathic  authorities  in  regard  to  its  frequent  indication  in 
iritis.  I  am  fully  convinced  of  its  homceopathicity  in  various 
conjunctival,  corneal  and  retinal  diseases,  but  in  iritis  no 
benefit  is  derived  from  its  use,  unless  the  lower  triturations  as 
the  Ix,  2x  and  3x  are  administered,  and  with  such  frequent 
repetition  of  the  dose  that  an  alterative  effect   is   produced. 


278  DISEASES  AND  INJURIES  OF  THE  EYE. 

When  administered  in  this  way  there  is  undoubtedly  a  marked 
effect  produced  upon  the  inflammation,  in  lessening  the  plastic 
exudation  which  is  so  marked,  particularly  in  syphilitic  cases. 
Its  true  homoeopathic  sphere  seems  to  be  in  those  cases  of 
iritis  which  approach  the  serous  variety,  or  when  the  plastic 
nature  of  the  exudation  is  not  marked.  Here  Merc.  cor.  in 
the  higher  dilutions  has  given  extremely  satisfactory  results. 

Nitric  acid. — A  valuable  remedy  in  the  chronic  and  recur- 
rent varieties  in  syphilitic  patients.  The  inflammatory 
symptoms  are  asthenic  and  the  pain  is  often  worse  during  the 
day  than  at  night. 

Rhus  iox. — In  plastic  and  suppurative  iritis  occurring  after 
operations  upon  the  eyeball,  or  plastic  inflammation  associated 
with  a  rheumatic  diathesis;  the  symptoms  are  intense  and 
accompanied  by  chemosis  and  swelling,  and  spasmodic  closure 
of  the  lids. 

Spigelia. — Very  suitable  to  cases  of  mild  iritis  where  the 
inflammatory  symptoms  are  not  marked  yet  accompanied  by 
severe  neuralgic  pains  in  and  around  the  eye. 

Sulphur. — In  the  suppurative  variety  with  hypopyon,  or  in 
the  chronic  form.  The  symptoms  are  variable  and  the  pre- 
scription must  be  made  upon  the  concomitant  conditions. 

Terebinth. — A  very  important  remedy  for  the  plastic  variety 
when  presented  in  rheumatic  patients,  with  the  urinary 
symptonis  characteristic  of  the  remedy. 

Thuja. — In  plastic  iritis  in  syphilitic  subjects  where  condy- 
lomata are  developed  in  the  tissue  of  the  iris. 

Among  other  remedies  which  may  be  useful  in  special  cases 
are  Pulsatilla,  Cedron,  Silicia,  Cimicifuga  and  Prunus  spinosa. 

IRITIS  SEROSA. 

Serous  iritis  is  a  low  form  of  inflammation  in  which  the 
pupil  is  usually  dilated.  Minute  flakes  of  lymph,  and  loosened 
epithelial  cells  from  the  surface  of  the  iris,  together  with  the 
serous'product  of  the  inflammation,  accumulate  in  the  anterior 
chamber  and  give  to  the  aqueous  a  turbid  appearance.     There 


IRITIS  SEROSA— TREATMENT.  279 

is  frequently  also  an  extension  of  the  inflammation  to  the 
membrane  of  Descemet  (or  descemetitis),  with  proliferation  of 
its  endothelial  cells,  and  the  appearance  upon  the  inner  surface 
of  the  cornea  of  minute,  whitish,  opaque  spots,  which  form  a 
ring  opposite  the  pupil,  or  have  a  triangular  shape  with  the 
apex  upward  as  already  described  under  keratitis  punctata. 
From  the  increase  of  the  contents  of  the  anterior  chamber  the 
iris  and  lens  are  pushed  backwards  and  the  anterior  chamber 
appears  much  deepened  and  the  intra-ocular  tension  is  often 
considerably  increased.  There  is  much  less  tendency  to 
adhesion  of  the  iris  to  the  lens  than  in  other  forms  of  iritis. 

Causes. — It  is  liable  to  occur  either  as  a  result  of  inflam- 
mation of  the  deeper  tissues,  as  the  ciliary  body  and  choroid, 
or  of  sympathetic  inflammation,  or  from  any  cause  which 
produces  general  debility,  as  prolonged  lactation  and  constitu- 
tional syphilis. 

Symptoms  and  Diagnosis.  —  As  already  stated,  there  is 
usually  a  partial  dilation  of  the  pupil,  the  iris  appears  dull  and 
is  very  slow  in  its  response  to  light.  The  vision  is  poor  from 
the  cloudy  condition  of  the  aqueous;  the  pain  is  not  marked, 
and  the  ciliary  zone  presents  but  slight  injection.  The  eye, 
however,  has  an  irritable  appearance  and  flushes  up  easily 
under  examination.  Examination  with  focal  illumination  is 
often  necessary  to  reveal  the  deposits  of  lymph  on  the  surface 
of  the  cornea.  There  is  no  febrile  reaction,  which  may  be 
present  in  other  forms  of  iritis,  and  there  is  so  little  general 
complaint  that  the  aff'ection  may  be  neglected  by  the  patient 
or  overlooked  by  the  physician.  Occasionally,  we  may  find  it 
taking  on  a  more  active  condition  in  cases  which  have  previ- 
ously had  iritis  and  resulting  adhesions.  The  disease  is  apt 
to  be  obstinate  and  very  protracted  and  the  prognosis  is 
often  doubtful. 

Treatment. — Atropine  or  duboisia  are  indicated  if  there  is 
any  tendency  to  adhesions,  or  if*  the  tension  is  not  markedly 
increased.  If  there  is  much  increase  of  tension  the  mydriatics 
will  not  be  absorbed  unless  paracentesis  is  performed.  The 
internal     administration    of    such   remedies    as    Gelsemium, 


280  DISEASES  AND  INJUKIES  OF  THE  EYE. 

Arsen.,  Bryonia,  Kali  bi.,  Kali  iod.,  will  be  indicated.  Eserine 
solution  externally  if  there  are  no  adhesions  will  often  cause 
a  subsidence  of  the  inflammation  without  operative  measures, 
which  consist  in  the  performance  of  a  large  iridectomy  in  pro- 
tracted cases. 

IRITIS  PLASTICA. 

Plastic  inflammation  of  the  iris  is  the  most  common  form  of 
iritis  and  has  already  been  described  under  the  general  head 
of  iritis.  It  is  characterized  by  the  exudation  of  coagulable 
lymph  into  the  structure  of  the  iris  and  gives  it  a  swollen 
appearance  and  collects  upon  the  surface  narrowing  or  occlud- 
ing the  pupil  and  gluing  the  posterior  surface  of  the  iris  to 
the  lens,  so  that  adhesions  occur  over  a  greater  or  less  extent 
of  its  surface,  and  on  the  administration  of  atropine  the  pupil 
does  not  dilate,  or  appears  irregular  as  in  Plate  IV,  Fig.  2. 
Adhesions  occur  early  and  there  is  a  narrowing  of  the  pupil- 
lary opening. 

In  some  cases  of  plastic  iritis  occurring  in  syphilitic  patients 
one  or  more  small  gummy  tumors  upon  the  iris  (Plate  IV,  Fig. 
8)  are  observed.  These  condylomata  may  be  reddish  in  color 
or  yellowish  and  are  pathognomic  of  the  syphilitic  variety  of 
iritis.  These  gummata  grow  rapidly  and  may  destroy  the  eye, 
but  usually  respond  readily  to  treatment  and  disappear  and 
leave  no  trace. 

The  vision  rapidly  deteriorates  in  plastic  iritis  from  the 
clouding  of  the  aqueous  or  the  occlusion  of  the  pupil.  There 
is  often  marked  febrile  excitement,  severe  pain,  photophobia 
and  lachrymation.  If  the  ciliary  body  becomes  involved,  the 
eyeball  becomes  sensitive  to  touch  especially  over  the  ciliary 
region. 

Treatment. — Atropine  must  be  used  as  early  as  possible 
and  the  adhesions  torn  or  the  dilatable  portions  of  the  iris 
withdrawn  as  far  as  possible.  The  atropine  should  be  applied 
every  two  or  three  hours  until  the  inflammatory  symptoms 
subside.  If  the  mydriatic  seems  to  lose  its  effect  or  produces 
no  effect  upon  the  pupil  or  the  tension  is  increased,  a  para- 


IRITIS  SUPPURATIVA— TREATMENT.  281 

centesis  of  the  cornea  should  be  made,  as  the  atropme  will  be 
more  readily  absorbed  afterward  and  the  operation  itself  will, 
if  properly  performed,  have  a  marked  influence  in  relieving 
the  irritation  of  the  eye ;  occasionally  better  results  are  obtained 
from  duboisia.  Hot  applications  are  to  be  applied  to  mitigate 
the  pain,  and  if  the  case  is  at  all  severe,  confinement  to  bed  is 
necessary. 

It  is  well  to  envelop  the  head  in  a  thick  layer  of  cotton 
which  should  be  worn  constantly,  and  particularly  at  night,  as 
it  lessens  the  tendency  to  the  nightly  Tittacks  of  pain  by  keep- 
ing up  an  equable  temperature  of  the  parts  about  the  eye. 

The  internal  use  of  Asafcetida,  Aurum,  Bry.,  China,  Clema- 
tis, Eserine,  Merc,  cor.,  Hepar  s.,  Kali  iod.,  Rhus  tox.,  Sulphur 
or  Terebinth,  according  to  the  indications  already  given,  will 
produce  rapid  cures. 

IRITIS    SUPPURATIVA. 

Purulent  iritis  may  begin  in  the  same  manner  as  the  plastic 
variety,  but  soon  the  j  us  which  has  permeated  the  iris  tissue 
and  produced  marked  changes  in  its  color,  finds  its  way 
into  the  anterior  chamber,  which  perhaps  it  half  fills,  forming 
hypopyon,  as  in  Plate  III,  Fig.  3.  Adhesions  may  form  as  in 
the  plastic  variety  and  it  presents  no  special  distinctive  symp- 
toms from  the  latter.  It  is  the  most  destructive  form  of  iritic 
inflammation  and  is  generally  the  result  of  injuries  to  the  iris, 
ulcerated  wounds  of  the  cornea,  or  after  operations  on  the 
eye,  and  is  frequently  the  result  of  the  extension  of  suppu- 
rative inflammation  of  the  choroid. 

Treatment. — Atropine  must  be  used  even  when  there  seems 
to  be  no  effect  upon  the  pupil.  Confinement  to  bed  and  the 
use  of  hot  wet  applications  are  necessary.  As  soon  as  hypo- 
pyon appears,  unless  the  pus  is  absorbed  and  the  condition 
improved  by  the  remedies,  a  paracentesis  should  be  made  and 
the  pus  allowed  to  flow  out  through  the  opening,  or  if  stringy 
and  thick  it  may  be  necessary  to  extract  it  with  a  pair  of  fine 
iris  forceps.  The  remedies  most  useful  will  be  Hepar  s.,  and 
Merc.  cor. 


282  DISEASES  AND  INJURIES  OF  THE  EYE. 

Ieitis  spongiosa  is  a  rare  inflammation  of  the  iris  which  is 
characterized  by  the  filling  of  the  anterior  chamber  with  a 
sero-fibrinous  exudation  which  has  a  delicate  smoky  or  bluish 
appearance.  The  aqueous  is  turbid  and  the  surface  of  the 
iris  hidden  by  the  exudation  which  may  be  soon  absorbed  or 
temporarily  disappear  on  paracentesis  of  the  cornea.  It  occurs 
after  cataract  extraction  and  in  some  cases  of  iritis  occurring 
in  aged  people,  but  is  a  rare  affection.  In  the  only  cases 
which  have  come  under  my  notice,  the  condition  rapidly  cleared 
up  under  Kali  bi.  and  Bryonia.  The  inflammatory  symptoms 
seemed  to  be  only  of  low  degree;  the  pain,  photophobia  and 
other  eye  symptoms  were  not  prominent. 

TUMORS  OF  THE  IRIS. 

Morbid  growths  on  the  iris  are  very  rare,  but  cases  are 
presented  occasionally  which  require  treatment. 

Sarcomata  and  Melanomata  are  very  rare,  and  when  occur- 
ring soon  involve  other  tissues  and  require  the  removal  of  the 
eyeball. 

Cysts  are  more  common,  although  still  very  rare,  and  are 
developed  in  the  iris  tissue  and  gradually  encroach  upon  the 
anterior  chamber,  or  extend  backward  toward  the  ciliary  body. 
They  usually  form  very  slowly  and  cause  no  disturbance  until 
they  increase  considerably  in  size  and  then  give  rise  to  pain. 

Treatment.  — The  best  method  of  treatment  consists  in  the 
excision  of  the  portion  of  the  iris  which  contains  the  cyst  by 
an  iridectomy. 

Granuloma  are  small  nodular  masses  of  granulation  tissue 
which  are  sometimes  seen  after  operations  upon  the  iris.  They 
require  no  treatment. 

CONGENITAL  MALFORMATIONS 

Irideremia  or  absence  of  the  iris  is  of  extremely  rare 
occurrence  and  is  accompanied  by  other  congenital  defects. 

CoLOBOMA  IiiiDis  or  cleft  iris,  occurs  either  in  one  eye  or 
in  both.  The  fissure  is  generally  below  but  may  be  above. 
There  is  often  a  corresponding  defect  in  the  choroid. 


FUNCTIONAL  DISEASES  OF  THE  IRIS— MYDRIASIS.  283 

Displaced  Pupil.— Sometimes  the  pupil  retains  its  rounded 
form,  but  is  placed  close  to  the  margin  instead  of  opposite  the 
centre  of  the  cornea.     The  condition  is  termed  Ectopia. 

Persistent  Pupillary  Membrane. — The  remnants  of  the 
membrane  -which  extend  across  the  pupil  in  the  foetus  some- 
times persist  after  birth  in  the  shape  of  fine  threads  extending 
across  the  pupil  or  upon  the  margin  of  the  iris.  They  demand 
no  operative  interference. 

functional  diseases  of  the  iris. 

Functional  disturbances  of  the  iris  occur  sympathetically 
■with  other  diseases.  In  certain  diseases,  as  apoplexy,  there 
may  be  first  a  dilatation  of  the  pupil  followed  by  its  contrac- 
tion during  the  stage  of  reaction.  In  meningitis,  however, 
the  pupil  is  contracted  in  the  first  stage,  while  as  the  disease 
advances  the  pupil  becomes  dilated.  In  attacks  of  hysteria 
the  pupil  is  first  contracted  and  becomes  dilated  later.  In 
spinal  sclerosis,  there  is  immobility  of  the  pupil  followed  by 
wide  dilation. 

mydriasis. 

Mydriasis  is  a  persistent  dilation  of  the  pupil  and  is  readily 
diagnosed  from  the  fact  that  the  pupil  does  not  contract  on 
exposure  to  light.  It  is  often  associated  with  paralysis  of  the 
accommodation.  Mydriasis  is  commonly  confined  to  one  eye 
but  both  may  be  affected.  The  dilation  may  be  partial  or 
complete.  The  dilation  of  the  pupil  results  from  paralysis  of 
the  branch  of  the  third  nerve  which  supplies  the  circular  or 
sphincter  muscle  of  the  iris.  The  same  effect  may  be  pro- 
duced by  the  irritation  of  the  cervical  branches  of  the  sympa- 
thetic which  are  distributed  to  the  dilator  fibres.  Large 
pupils  occur  in  myopes  because  they  do  not  use  their  accom- 
modation and  also  in  persons  who  are  much  debilitated,  or 
suffering  from  anaemia,  but  in  these  cases  the  pupil  is  not 
inactive  nor  is  the  dilatation  as  great  as  in  mydriasis. 


284  DISEASES  AND  INJURIES  OF  THE  EYE. 

Causes. — Mydriasis  appears  as  the  toxic  effect  of  certain 
drugs  as  atropine,  liomatropine,  liyoscyamine,  cluboisia,  da- 
turine,  gelsemine  and  others.  It  is  not  infrequently  a  sequela 
of  diphtheria  and  may  precede  or  accompany  other  muscular 
paralyses  from  the  same  cause.  Traumatic  injuries,  concussion 
of  the  brain,  syphilis,  meningitis,  hydrocephalus,  cerebral 
tumors,  sudden  checking  of  the  perspiration,  rheumatism, 
neurasthenia,  exhaustion,  intestinal  irritation  and  loco-motor 
ataxia  may  all  be  exciting  causes. 

Treatment. — Those  cases  which  respond  to  treatment  are 
dependent  upon  diphtheritic  or  syphilitic  causes.  Here  Gels., 
Bell.,  Physostig.,  Arg.  nit.,  or  Kali  iod.,  will  be  among  the 
indicated  remedies. 

In  other  cases  but  little  benefit  is  derived  from  treatment, 
Tinless  the  more  serious  affection  can  be  relieved.  When 
associated  with  paralysis  of  the  accommodation  and  of  the 
ocular  muscles,  the  remedies  suggested  for  their  treatment 
may  relieve  the  mydriasis. 

When  occurring  from  the  accidental  instillation  of  atropine, 
it  may  be  partially  relieved  by  the  use  of  pilocarpine  or  eserine 
externally. 

MYOSIS. 

Myosis  or  contraction  of  the  pupil  is  the  opposite  of 
mydriasis  and  results  from  paralysis  of  the  sympathetic,  or 
irritation  of  the  third  nerve,  and  may  accompany  spasm  of 
the  accommodation. 

Causes. — Contraction  of  the  pupil  occurs  in  poisoning  from 
opium  or  its  alkaloids,  from  instillations  of  eserine,  pilocar- 
pine and  some  other  drugs.  It  is  sometimes  traumatic  in  its 
origin,  as  from  injuries  to  the  cornea  or  from  the  presence  of 
foreign  bodies.  When  the  contraction  is  reflex  from  irritation 
of  the  fifth  nerve,  it  is  sometimes  associated  with  atrophy  of 
the  optic  nerve  from  cranial  causes.  It  may  arise  from  an 
over-sensitive  condition  or  hypertesthesia  of  the  retina  and 
fi-om  growths  which  cause  pressure  upon  the  cervical   sympa- 


MYOSIS— OPERATIONS  UPON  THE  IRIS.  285 

tlietic,  and  from  lesions  of  the  cervical  portions  of  the  spinal 
cord. 

Treatment.  —  This  must  be  directed  to  the  cause  of  the 
disease. 

HiPPUS  is  a  rare  affection  in  which  there  is  a  rapid  dilation 
and  contraction  of  the  pupil.  In  the  only  case  I  have  seen  it 
■was  congenital  and  associated  with  a  clonic  contraction  of  the 
levator  superioris  and  affected  the  right  eye  only.  The 
spasmodic  condition  became  very  prominent  on  any  excite- 
ment of  the  child. 

Iridodonesis,  or  a  tremulous  condition  of  the  iris,  is 
dependent  upon  a  fluid  condition  of  the  anterior  part  of  the 
vitreous  or  from  the  loss  of  its  natural  support,  the  lens,  and 
is  seen  after  the  extraction  of  the  lens  in  its  capsule  for  cata- 
ract, or  when  there  is  luxation  of  the  lens  into  the  vitreous. 

OPERATIONS  UPON  THE  IR1§.  , 

Iridectomy.  —  This  operation,  which  was  brought  into 
prominence  by  Von  Graefe,  is  the  most  frequent  operation 
upon  the  iris,  and  has  a  most  decided  influence  in  checking 
some  destructive  processes  in  the  eye  when  accompanied  by 
intra-ocular  tension,  as  in  glaucoma,  cyclitis,  or  irido-choroid- 
itis.  It  may  be  useful  in  chronic  iritis  especially  when 
recurrent,  or  when  there  are  extensive  adhesions,  and  in  some 
cases  of  keratitis,  or,  for  the  removal  of  foreign  bodies  in  the 
anterior  chamber  or  upon  the  iris  or  lens.  It  is  also  prelim- 
inary to  cataract  extraction,  or  is  made  for  the  formation  of  a 
new  pupil  in  opacities  of  the  cornea,  or  stationary  opacities  of 
the  lens.  In  making  an  iridectomy  the  purposes  for  which  it 
is  done  are  to  be  considered.  If  it  is  for  lessening  the  tension 
as  in  glaucomatous  conditions  of  the  eye,  a  large  part  of  the 
iris  is  to  be  removed  and  the  upper  portion  is  to  be  selected 
in  all  cases  where  there  is  no  contra-indication,  as  the  upper 
lid  then  covers  the  deformity  to  a  large  extent.  If  it  is 
preliminary  to  cataract  extraction,  it  is  to  be  made  in  the  same 
direction  as  that  of  the  incision  for  the  removal  of  the  lens. 


286  DISEASES  AND  INJURIES  OF  THE  EYE. 

When  made  for  the  purpose  of  improving  tiie  vision,  llie  best 
situation  is  inward  and  downward  if  the  corneal  opacity  and 
the  other  lesions  will  permit  it;  if  not,  then  it  should  be  made 
directly  inward,  downward  or  outward,  as  the  condition  may 
decide.       The  extent  of  the  iris  to  be  removed  will  depend 


upon  the  indications  for  the  operation ;  if  made  for  therapeuti- 
cal purposes,  as  in  glaucoma,  a  large  portion  should  be  excised, 
perhaps  one-fourth  or  one-third  of  the  iris;  if  for  improvement 
of  the  vision,  then  a  small  fissure  may  be  sufficient,  perhaps 
not  more  than  one  or  two  lines  or  2  to  4  mm.     The  location  of 


^^«E 


£IG.  101. 


the  incision  will  ajso  depend  upon  the  indications  for  the  oper- 
ation ;  if  for  therapeutic  purposes,  it  will  be  made  in  the  sclero- 
corneal  junction,  while  for  optical  purposes  within  the  cornea. 
The  instruments  necessary  are  a  speculum,  to  separate  the  lids, 
a  pair  of  fixation  forceps,  a  lance-shaped  keratome,  straight  or 


curved  as  in  Figs.  100  and  101,  or  a  linear  cataract  knife  (Fig. 
102),  a  pair  of  straight,  or  curved  iris  forceps  (Fig.  103)  and 
a  pair  of  straight,  or  curved  iris  scissors  (Figs.  104  and  105). 
If  it  is  desired  to  make  a  very  broad  iridectomy,  or  if  the 
anterior  chamber  is  shallow,  a  narrow  cataract  knife  is  more 


FIG  103. 

suitable  than  a  lance-shaped  keratome.  When  a  small  portion 
of  the  iris  is  to  be  removed,  a  small  lance-shaped  keratome 
answers  the  purpose  better.     The  operation  is  performed  in 


OPERATIONS  UPON  THE  IRIS. 


287 


the  following  manner:  An  anaesthetic  may  be  used  or  not 
according  to  the  judgment  of  the  surgeon.  The  patient  is 
placed  in  a  recumbent  position  and,  if  an  anaesthetic  is  used, 
when  the  cornea  is  no  longer  sensible  to  the  touch  of  the  finger, 
a  speculum  with  the  blades  closed  is  introduced  between  the 
lids  and  the  latter  widely  separated.  The  eyeball  is  then 
steadied  by  seizing  the  conjunctiva  with  fixation  forceps  at  a 


FIG.  10*. 


point  close  to  the  corneal  margin  and  opposite  the  position  of 
the  intended  incision.  The  forceps  are  held  in  the  left  hand 
while  the  operator  takes  the  lance-shaped  knife  in  the  right 
hand.  In  making  the  incision  the  tough  nature  of  the  cornea 
must  be  remembered,  and  if  the  force  applied  to  the  knife  is 
not  proportioned  to  the  resistance  of  the  cornea,  the  knife  may 
be  suddenly  pushed  into  the  anterior  chamber  and  the  iris  or 


lens  wounded.  If  the  proper  direction  is  not  given  to  the 
knife,  it  may  split  the  layers  of  the  cornea  and  not  enter  the 
anterior  chamber,  an  accident  which  may  be  disastrous.  The 
point  of  the  .knife  is  now  directed  towards  the  centre  of  the 
eyeball  at  the  location  of  the  incision,  and  gently  passed 
through  the  cornea,  when  its  direction  is  changed  by  depress- 
ing the  handle  until  the  blade  of  the  knife  is  parallel  to  the 


288 


DISEASES  AND  INJURIES  OF  THE  EYE. 


FIG.  106. 


surface  of  the  iris,  wlieu  the  incision  is  completed  by  turning 
the  blade  first  to  one  side  and  then  another,  until  the  inner 
line  of  the  incision  is  of  the  same  length  as  the  outer.  The 
knife  is  then  gently  withdrawn  and  the  anterior  chamber  is 
emptied  by  the  aqueous  finding  an  exit  through  the  wound, 

and  the  iris  and  lens  move 
forward.  The  fixation  for- 
ceps are  now  removed  and 
the  iris  forceps  are  then 
taken  in  the  left  hand  and 
the  scissors  in  the  right, 
the  forceps  are  introduced 
closed  into  the  wound  and 
then  allowed  to  open,  and 
the  iris,  as  it  floats  between  the  blades,  is  seized  and  withdrawn, 
put  slightly  on  the  stretch,  and  with  one,  two,  or  three  cuts  o£ 
the  scissors,  the  portion  desired  is  removed.  Blood  may  be 
effused  into  the  anterior  chamber  and  may  be  removed  by 
slight  pressure  upon  the  scleral  edge  of  the  wound  with  a 
spatula,  and  the  application  of  a  bit  of  soft  linen  to  the  wound, 
but  no  considerable  effort  or  pressure  should  be  used  as  the 
blood  will  be  speedily  absorbed;  no  portion  of  the  iris  or  small 
clot  must  be  left  in  the  wound.  A  few  drops  of  boracic  acid 
solution  may  be  dropped  into  the 
eye  to  wash  out  any  blood  or  secre- 
tion of  the  conjunctiva.  A  compress 
bandage  is  then  applied  and  the 
patient  placed  in  bed.  In  all  cases 
where  there  has  been  no  increased 
tension,  a  drop  of  atropine  solution 
is  put  in  at  the  next  dressing.  Fig. 
106  shows  the  position  of  the  wound 
Avhen  the  iridectomy  is  made  outward;  Fig.  107  the  with- 
drawal of  the  iris  by  the  forceps  and  the  application  of  the 
scissors  which  are  applied  close  to  the  sclera  before  the  cutting. 
Fig.  108  shows  the  appearance  of  the  coloboma,  or  fissure  of 
the  iris,  after  the  operation,  the  dotted  lines  showing  the  loca- 


riG.  107. 


OPERATIONS  UPON  THE  IRIS. 


289 


tion  of  the  wound  when  made  within  the  sclera.  "When  the 
anterior  chamber  is  \eYy  shallow,  as  in  glaucomatous  conditions, 
the  operative  procedure  is  the  same  as  before,  except  that  a 
narrow  cataract  knife  (Fig.  102)  is  used  and  the  point  of  the 
knife  introduced  into  the  extreme  limit  of  the  anterior  chamber, 
or  about  half  a  line,  or  1  mm.,  or  even 
more,  behind  the  transparent  edge  of 
the  cornea,  and  an  incision  made  par- 
allel to  the  surface  of  the  iris;  the  iris 
is  well  drawn  out  and  cut  off  close  to 
FIG.  108.  its  attachment  with  two  or  three  strokes 

of  the  scissors.  Fig.  109  shows  the  line  of  incision  and  the 
size  of  the  coloboma  when  made  in  an  upward  direction.  The 
eje  is  bandaged  as  before  and  the  dressing  changed  once  a 
day,  but  no  atropine  used. 

The  reaction  following  these  opera- 
tions upon  the  iris  is  usually  very 
sljglit  if  properly  done,  and  no  acci- 
dents have  occurred.  The  internal 
administration  of  Aconite,  Arnica  or 
Calendula  undoubtedly  hastens  the 
recovery  and  prevents  possible  in- 
flammatory action. 

Ikidotomy,  or  Wecker's  incision  of  the  iris,  is  an  operation 
which  is  sometimes  required  after  the  removal  of  the  lens  for 
cataract.  The  iris,  from  inflammation  following  extraction, 
becomes  adherent  to  the  lens  capsule  by  the  formation  of  a 

false  membrane,  or  the  pupil 
is  occluded.  The  operation  is 
performed  as  follows:  An  in- 
cision is  made,  usually  at  the 
upper  part  of  the  cornea,  about 
one-fourth  of  an  inch  long  by  a  keratome,  the  point  being 
pushed  obliquely  downward  through  the  pupil  into  the 
vitreous.  Into  the  corneal  wound,  Wecker's  scissors,  or  Lie- 
bold's  (Fig.  110)  are  introduced  closed.  When  the  point 
reaches  the  opening  in  the  pupil,  the  blades  are  allowed  to 

19 


FIG.  109. 


FIG.  110. 


290  DISEASES  AND  INJURIES  OF  THE  EYE. 

open,  and  one  is  passed  behind  and  the  other  in  front  of  the 
iris,  which  is  divided  by  a  single  cut.  The  iris,  which  has 
been  upon  the  stretch,  immediately  separates  and  a  slit  pupil 
results.  In  some  cases  two  cuts  may  be  required  and  a  some- 
what triangular-shaped  pupil  is  made.  Atropine  is  instilled, 
a  bandage  applied,  and  rest  prescribed  for  three  or  four  days. 

Iridodesis,  or  Critchett's  operation,  consists  in  making  an 
opening  in  the  cornea  anterior  to  the  scleral  junction,  drawing 
out  the  iris  with  a  hook  and  tying  a  fine  silk  thread  around 
the  withdra'N^Ti  iris,  and  leaving  the  latter  to  slough  off.  The 
pupil  by  this  means  is  dragged  opposite  a  portion  of  clear 
cornea.  The  operation,  however,  is  liable  to  lead  to  cyclitis 
or  sympathetic  ophthalmia,  and  has  been  superseded  by  the 
operation  of  iridectomy. 

CoRELYSis  is  an  operation'  devised  for  the  separation  of 
the  adhesions  of  the  iris  to  the  lens  capsule.  A  small  incision 
is  made  in  the  cornea  and  a  blunt  hook  or  toothless  iris  for- 
ceps introduced  and  the  adhesions  separated  by  traction;  the 
clanger  of  rupture  of  the  capsule  and  contusion  of  the  iris  is 
great,  hence  the  operation  is  not  commonly  performed. 

Iridodialysis. — In  opacities  of  the  cornea  where  only  a 
narrow  rim  of  transparent  tissue  remains,  instead  of  making 
an  iridectomy,  which  would  leave  a  hazy  scar  at  the  margin 
where  the  incision  is  made,  an  opening  is  made  through  the 
opaque  portion,  a  pair  of  fine  forceps  introduced  and  the  iris 
gently  torn  from  its  attachment  beneath  the  transparent  por- 
tion of  the  cornea,  and  a  portion  of  the  iris  drawn  out  through 
the  wound  and  cut  off  close  to  the  surface. 


CHAPTEK     XIV. 

DISEASES    OF    THE    CILIAKY    BODY. 

ANATOMY. 

The  ciliary  body  consists  of  a  plaited  zone  containing  the 
ciliary  process  and  the  ciliary  muscle,  lying  between  <the  iris 
and  the  ora  serrata,  and  is  a  direct  continuation  of  the  choroid. 
It  is  made  up  of  the  ciliary  processes,  meridional  folds  of  the 
choroid,  some  seventy  to  eighty  in  number,  which  rise  gradu- 
ally from  the  ora  serrata  and  are  continued  forward  to  the  iris. 
Tliese  processes  have  the  same  structure  as  the  choroid,  except 
its  capillary  layer,  and  are  covered  by  the  retinal  pigment.  In 
the  depressions  formed  by  the  plaits,  fit  corresponding  projec- 
tions of  the  zonule  of  Ziiin,  a  transparent  membrane  contin- 
uous -with  the  envelope  of  the  vitreous  and  which  also  forms 
the  suspensory  ligament  of  the  lens. 

The  ciliary  muscle  occupies  the  anterior  and  more  internal 
portion  of  the  ciliary  body  between  the  ciliary  process  and  the 
sclerotic,  and  consists  of  bundles  of  grayish,  unstriped  mus- 
cular fibres  which  take  three  different  directions.  The  outer, 
near  the  sclerotic,  which  form  the  thickest  part  of  the  muscle, 
arise  from  a  tendinous  ring  on  the  inner  side  of  the  canal  of 
Schlemm,  take  a  meridional  direction  and  are  lost  in  the  cho- 
roid; the  middle  fibres  diverge  in  an  oblique  direction  and 
form  a  circular  plexus,  while  the  third  layer  occupies  the 
anterior  and  most  internal  portion  of  the  ciliary  body  and  is 
made  up  of  separate  circular  bundles  which  form  the  sphincter, 

391 


292  DISEASES  AND  INJURIES  OF  THE  EYE. 

or  ring  muscle  of  Mtlller.  The  ciliary  muscle  is  supplied  by 
a  filament  from  the  third  nerve,  which  has  been  stated  to  have 
a  separate  origin  in  the  brain,  and  is  probably  the  exclusive- 
agent  in  the  production  of  accommodation. 

The  ciliary  body  is  firmly  joined  to  the  sclera  at  the  sclero- 
corneal  junction,  more  posteriorly  it  is  loosely  attached  to  the 
sclera  by  the  supra-choroidea  and  is  largely  supplied  with 
congeries  of  fine  blood-vessels  which  also  form  two  arterial 
circles,  whose  office  is  to  afibrd  nourishment  for  the  crystalline 
lens  and  to  secrete  the  aqueous  humor.  It  is  highly  supplied, 
with  ciliary  nerves  derived  from  the  long  and  short  ciliary, 
which  form  a  rich  plexus  with  minute  nerve  ganglia  in  its- 
tissue,  while  all  the  nerves  which  go  to  the  iris  pass- 
through  it. 

.       DISEASES  OF  THE  CILIARY  BODY. 

The  ciliary  body,  from  its  situation  between  the  iris  and 
choroid,  and  its  direct  connection  with  them  through  similarity 
of  structure,  is  liable  to  participate  in  inflammation  of  these 
structures.  In  inflammation  of  the  iris  the  ciliary  body  is 
likely  to  be  afiected  by  the  extension  of  the  inflammation  back- 
ward, while  if  the  ciliary  body  becomes  the  seat  of  inflam- 
mation the  iris  is  almost  sure  to  become  inflamed.  Since  the 
nourishment  of  the  lens  and  the  anterior  portion  of  the 
vitreous  is  mainly  derived  from  the  ciliary  body,  any  diseased 
condition  of  the  latter  interferes  at  once  with  their  proper 
nutrition,  and  changes  occur,  which  may  result  in  opacities  or 
in  a  cataractous  condition  of  the  lens,  or  a  fluid  condition  o£ 
the  vitreous.  The  abundant  nerve  supply  of  the  ciliary  body, 
which  brings  it  into  such  intimate  relation  with  all  important 
parts  of  the  eye,  renders  any  inflammation  of  the  part  likely 
to  lead  to  serious  complications  and  hence  is  of  the  utmost 
importance  and  exceedingly  dangerous.  It  is  impossible, 
except  in  very  rare  cases,  to  separate  inflammations  of  the 
ciliary  botly  from  those  of  the  iris,  as  it  is  impossible  to- 
examine  the  condition  with  the  ophthalmoscope  and  the  inflam- 


CYCLITIS—IRIDO  CYCLITIS.  293 

mation  extends  so  rapidly  to  the  iris  that  the  diseased  condition 
of  the  latter  masks  that  oi  the  former. 

CYCLITIS. 

Symptoms  and  Diagnosis. — Hyper^emia  and  inflammation  of 
the  ciliary  body  is  characterized  by  injection  of  the  vessels  of 
the  ciliary  zone,  congestion  of  the  conjanctiva,  intense  photo- 
phobia and  lessened  vision,  without  marked  change  in  the  iris 
beyond  the  hyperremic  condition.  There  is  exquisite  tender- 
ness over  some  portion,  or  the  whole,  of  the  ciliary  region 
when  pressed  upon  through  the  closed  licL  There  are  also 
severe  neuralgic  pains  which  affect  the  whole  eyeball  and  the 
fiide  of  the  head,  even  extending  down  the  neck.  The  anterior 
portion  of  the  vitreous  becomes  clouded  and  examination  with 
the  ophthalmoscope  is  impossible.  Tension  may  be  doubtful, 
or,  as  the  disease  advances,  becomes  increased  and  atropine 
lias  but  little  effect  upon  the  iris  or  upon  the  paroxysms  of 
pain.  A  suppurative  stage  may  even  be  entered  upon  without 
a  purulent  inflammation  of  the  iris  occurring,  and  pus  may 
appear  behind  the  lens  or  in  the  anterior  chamber. 

Causes. — Low  conditions  of  the  system,  suppressed  menstru- 
ation, and  slight  or  ill-treated  attacks  of  iritis,  seem  to  excite 
ii  It  has  been  observed  in  children  after  typhoid  or  scarlet 
fever.  It  may  also  occur  from  syphilis,  rheumatism  and 
*jtruma,  ;iiid  be  consequent  upon  diseases  of  the  cornea. 

Treatment. — Hot  applications,  moist  or  dry,  according  to 
the  comfort  of  the  patient,  should  be  used  and  absolute  rest  of 
the  eye  during  the  attack  of  the  inflammation  and  for  a  long 
period  after  recovery  has  taken  place  prescribed.  The  general 
treatment  of  the  acute  affection  will  be  similar  to  that  of  iritis 
and  atropine  or  duboisia  are  to  be  used  as  in  iritis.  Much 
attention  must  be  given  to  the  general  health,  and  the  diet 
made  nutritious  and  generous  if  the  patient  is  ill-nourished 
or  in  a  feeble  condition.  The  chief  reliance  must  be  placed 
upon  the  use  of  internal  remedies,  the  general  indications  for 
which  will  be  found  amongst  those  which  have  been  already 


294  DISEASES  AND  INJURIES  OF  THE  EYE. 

given  under  iritis.  Among  those  remedies,  Bell.,  Bry..  Gels., 
Hepar,  Kali  iod.,  Merc,  cor.,  Merc,  iod.,  Rhus  or  Silicia  will 
be  likely  to  be  useful.  ^ 

IRIDO  CYCLITIS. 

Symptoms  and  Diagnosis. — Inflammations  of  the  iris  when 
extended  to  the  ciliary  body,  exhibit  either  a  serous,  plastic, 
or  purulent  form;  there  is  consequently  exudation  and  swell- 
ing of  the  structures  of  both,  with  exudation  into  the  posterior 
chamber  and  behind  the  lens.  The  vascularity  and  pain  are 
greater  than  when  the  iris  alone  is  affected,  and  there  is  sharp 
pain  which  causes  the  patient  to  suddenly  shrink  back  when 
the  ciliary  region  is  touched  through  the  closed  lid  by  the 
finger.  The  vision  becomes  greatly  impaired  from  the 
opacities  in  the  vitr(?ous  and  there  is  scarcely  any  dilation  of 
the  pupil  when  atropine  is  used.  In  the  serous  variety  there 
is  increased  tension  in  the  acute  form,  which  in  the  chronic 
form  is  replaced  by  a  soft  condition  of  the  eyeball  which 
results  in  atrophy  of  the  globe,  or  FMhisis  hiilhi.  The  iris 
becomes  discolored,  often  grayish  and  atrophied. 

In  the  plastic  inflammation  the  iris  becomes  attached  over 
the  whole  surface  of  the  lens  and  dense  whitish  masses  fill  the 
posterior  chaml)er,  often  extending  up  onto  the  posterior  sur- 
face of  the  lens  and  into  the  vitreous.  These  masses  of 
exudation  in  and  upon  the  ciliary  body  contract,  after  a  time, 
and  draw  the  iris  backward,  deepening  the  anterior  chaml^r, 
and  bringing  about  changes  in  the  ciliary  body  itself,  the 
vitreous  and  also  the  hms.  The  suppurative  condition  rapidly 
involves  the  whole  eye,  producing  pdnopMludmUis  with  com- 
plete destruction  of  the  eye.  The  period  of  cong-estion  may 
be  short  and  the  pus  in  the  anterior  chamber  noticed  among 
the  early  symptoms.  The  prognosis  is  more  grave  than  when 
the  iris  alone  is  implicated,  as  the  changes  in  the  \dtreous, 
lens  or  choroid,  which  result,  destroy  vision. 

Causes. — The  causes  are  the  same  as  those  already  given 
under  cyclitis. 


TRAUMATIC  CYCLITIS—THE  CILIARY  MUSCLE.  295 

Treatment. — This  does  not  differ  from  that  of  the  various 
forms  of  iritis  which  may  involve  the  ciliary  body. 

TRAUMATIC  CYCLITIS. 

The  most  frequent  form  of  inflammation  of  the  ciliary  body 
is  that  arising  from  injuries  of  tliis  structure,  as  wounds,  or 
lacerations  of  the  eyeball  in  the  ciliary  region ;  wounds  in  this 
region  being  more  dangerous  than  in  any  other  part  of  the 
eye.  The  penetration  of  the  ciliary  body  by  small  bodies  of 
any  description,  or  their  lodgment  in  it,  are  very  prone  to 
excite  a  most  destructive  inflammation  of  the  part  and  become 
a  very  common  cause  of  sympathetic  ophthalmia.  The  ciliary 
body,  under  these  circumstances,  becomes  the  seat  of  a  plastic 
inflammation  which  rapidly  disturbs  the  relation  of  the  interior 
structures  of  the  eye  to  eacii  other.  These  masses  of  white 
exudation  oftentimes  extend  out  into  the  vitreous  and  onto 
the  retina,  becoming  organized  connective  tissue,  which,  after 
a  time,  contracts  and  causes  separation  of  the  retina  from  the 
choroid,  or  even  detachment  of  the  ciliary  body  from  the 
sclera. 

Symptoms.  —  The  symptoms  do  not  differ  from  those  of 
cyclitis  from  other  causes. 

Treatment. — In  the  beginning  cold  applications  should  be 
made,  as  the  attack  may  be  aborted  by  their  use.  "Where  the 
disease  has  become  established,  it  is  to  be  treated  as  indicated 
for  cyclitis.  Later,  it  may  become  necessary  to  remove  the 
eyeball.  If  there  is  a  foreign  body  within  the  ciliary  body,  or 
within  the  eyeball,  and  cyclitis  is  imminent,  enucleation  should 
be  practised  at  once. 

FUNCTIONAL  DISEASES  OF  THE  CILIARY  MUSCLE. 

Paralysis  op  the  Accommodation. — Cycloplegia,  or  paraly- 
sis of  the  ciliary  muscle,  Avliich  causes  total  loss  of  power  of 
the  accommodation,  is  usually  associated  Avith  mydriasis  from 
paralysis  of  the  sphincter  pupillcc,   as  both   are  supplied  by 


296  DISEASES  AND  INJURIES  OF  THE  EYE. 

branches  of  the  motor  fibres  of  the  ciliary  ganglion.     One  eye 
alone  is  generally  afiected,  though  the  paralysis  may  aifect  both. 

Symptoms. — The  marked  dilatation  of  the  pupil,  together 
•with  the  loss  of  power  of  distinguishing  near  objects,  indicates 
this  condition.  If  vision  is  restored  to  its  normal  condition 
by  a  convex  glass  tlie  diagnosis  is  then  complete.  Objects 
often  appear  smaller  because  they  seem  nearer  than  they  really 
are.  In  myopes  the  disturbance  may  be  very  slight,  but  with 
hyperopes  the  distant  vision  may  also  be  affected,  so  that  vision 
is  much  lessenecL 

Causes. — The  paralysis  may  arise  from  idiopathic,  trau- 
matic, syphilitic  and  rheumatic  causes  affecting  the  third 
nerve,  or  result  from  the  use  of  mydriatic  drugs.  When 
idiopathic  the  condition  may  have  been  excited  by  prolonged 
use  of  the  eyes  for  near  and  fine  objects.  More  or  less  com- 
plete paralysis  may  occur  after  diphtheria  and  is  then  usually 
accompanied  by  some  paralysis  of  the  soft  piiate,  and  without 
affection  of  the  mobility  of  the  eye.  Blows  upon  the  eye 
sometimes  cause  it.  Syphilis  and  rheumatism  are  the  more 
frequent  causes,  and  the  lesion  may  exist  in  the  brain  or  in 
the  course  of  the  branches  of  the  third  nerve,  in  the  orbit,  or 
in  the  ciliary  ganglion.  Mydriatics  affect  the  accommodation 
as  well  as  cause  dilatation  of  the  pupil.  Atropine  and  lioma- 
tropine  are  more  commonly  used  for  the  purpose  of  paralyzing 
the  accommodation  than  the  other  mydriatics,  and  the  former 
much  more  frequently  than  the  latter. 

Treatment. — The  treatment  must  be  directed  to  the  cause, 
and,  as  already  stated,  the  paralysis  is  often  symptomatic  of 
some  deep-seated  and  serious  affection,  hence  will  require  such 
remedies  as  may  be  adapted  to  this  condition,  as  it  is  fre- 
quently associated  with  paralysis  of  the  other  ocular  muscles. 
The  treatment  is  the  same  as  that  already  discussed  for  paraly- 
sis of  the  muscles.  When  uncomplicated,  the  use  of  such 
remedies  as  Causticum,  Arg.  nit,  Dubois.,  Physostig.,  Kali 
iod.,  Opium  and  Paris  quad,  may  be  beneficial.  Faradization 
or  galvanization  is  often  of  benefit  in  addition  to  the  internal 
remedies.  Eserine,  or  pilocarpine,  locally  is  sometimes  of 
benefit  in  stimulating  the  paralyzed  muscle. 


DISEASES  OF  THE  CILIARY  MUSCLE— REMEDIES.  297 

Paresis  of  the  Accommodation,  or  Accommodative  asthen- 
opia, is  much  more  common  than  paralysis  and  is  not  accom- 
panied by  any  change  in  the  mobility  of  the  eyes.  It  is 
frequently  associated  with  a  potential  weakness  of  the  extrinsic 
muscles  of  the  eyeball. 

Symptoms. — The  external  appearance  of  the  eye  may  give 
no  indication  of  the  weakness  of  the  accommodation.  The 
eye  may  appear  clear,  the  action  of  the  extrinsic  muscles  good, 
the  pupil  normal,  the  ophthalmoscopic  appearances  negative, 
and  the  visual  power  perfect,  but  the  effort  at  reading  or  doing 
fine  work  cannot  be  continued  except  for  a  very  short  time.  A 
feeling  of  fatigue  and  tension  comes  on  so  that  the  eyes  must 
be  closed  and  rested  for  a  few  moments  until  they  regain  their 
f)ower.  Objects  may  become  indistinct,  the  letters  in  reading 
blur,  the  eyes  feel  hot  or  painful,  and  an  aching  arises  in  the 
brow  and  severe  frontal  or  occipital  headache  follows  and, 
perhaps,  nausea  and  vomiting,  if  the  effort  is  continued  or  the 
attempt  to  read  is  made  by  a  dull  or  artificial  light.  AVhen 
the  condition  has  existed  for  a  time,  conjunctival  or  retinal 
hyperaemia  may  result. 

Causes. — The  common  causes  of  loss  of  tone  of  the  ciliary 
muscles  are  refractive  errors;  these  may  be  very  slight  and 
will  require  careful  investigation.  The  agency  of  hyperopia 
in  causing  accommodative  asthenopia  has  already  been  consid- 
ered. The  weaker  degrees  of  astigmatism  are  often  the 
exciting  causes.  The  paretic  condition  and  the  development 
of  the  asthenopic  symptoms  seem  to  depend  greatly  upon  the 
degree  of  irritability  of  the  nervous  system  of  the  individual. 
It  is  frequently  the  result  of  general  weakness  and  follows 
acute  diseases  or  occurs  during  the  course  of  chronic  constitu- 
tional diseases. 

If  is  a  frequent  accompaniment  of  general  neurasthenia,  or 
the  affection  of  the  ciliary  muscle  may  occur  subsequent  to 
the  improvement  of  the  general  tone.  It  is  often  a  sequela  of 
typhoid,  and  acute  exanthematous  fevers,  or  is  associated  with 
diseases  of  the  uterus  and  digestive  tract. 

Treatment. — Glasses   which    correct    any  refractive    error 


298  DISEASES  AND  INJURIES  OF  THE  EYE. 

that  may  be  discovered  must  be  prescribed,  and  attention 
given  to  the  improvement  of  the  general  tone  of  the  system. 
A  good  and  generous  diet  is  oftentimes  necessary  in  these 
cases,  as  well  as  moderate  and  daily  exercise.  The  galvanic 
current,  with  one  pole  upon  the  closed  eyelids  and  the  other 
upon  the  nape  of  the  neck,  is  often  a  valuable  adjuvant  in  the 
treatment.  The  methodical  exercise  of  the  eyes  in  reading,  as 
directed  for  muscular  asthenopia,  will  also  be  useful.  In  addi- 
tion to  the  indications  for  the  remedies  given  under  muscular 
asthenopia  which  is  often  associated  with  accommodative 
asthenopia,  the  following  should  be  consulted. 

REMEDIES. 

Duhoisia. — Paresis  of  the  ciliary  muscle.  The  accommoda- 
tive effort  can  be  sustained  only  momentarily  and  hypercemia 
of  the  conjunctiva  and  lachrymation  occur  from  attempted  use 
of  the  eyes. 

Conium. — The  letters  run  together  on  reading  and  the  effort 
brings  on  vertigo  or  headache.  Burning  pain,  deep  in  the  eye, 
may  be  complained  of  and  the  light  is  usually  disagreeable  or 
painful. 

Physosiigma. — While  more  valuable  in  spasmodic  affections 
of  the  ciliary  muscle,  it  is  also  curative  in  some  cases  of  paresis 
of  the  accommodation  following  diphtheria. 

Argentum  nit.  —  Paresis  following  diphtheria,  or  in 
hyperopes,  and  weakness  of  the  accommodation  after  herpes 
frontalis. 

Liliiim  /«'(/.— Weakness  of  the  accommodation  which  has 
been  preceded  by  an  irritable  condition  of  the  ciliary  muscle. 
There  is  usually  photophobia,  burning,  smarting  and  heat  of 
the  eyes  after  use,  and  general  relief  of  the  eye  symptoms 
from  the  open  air. 

Jahorandi.  —  Alternate  contraction  and  relaxation  of  the 
ciliary  muscle  associated  with  uterine  disturbance  or  with 
refractive  errors.  The  effort  to  read  or  use  the  eyes  for  near 
work  frequently  causes  nausea  and  even  vertigo. 


SPASM  OF  THE  ACCOMMODATION— CAUSES.  299 

Spasm  of  the  Accommodation. — Touic  spasm  of  the  ciliary 
muscle  is  not  uncommou  in  liypermetropes,  astigmatics  and 
myopes  and  also  occurs  in  normal  eyes.  It  frequently  compli- 
cates muscular  asthenopia.  The  contraction  of  the  muscle 
relaxes  the  suspensory  ligament,  so  that  the  lens  is  constantly 
in  a  state  of  increased  convexity  and  the  function  of  accom- 
modation is  interfered  with  and  myopia  simulated. 

Symptoms  and  Diagnosis. — Distant  objects  are  only  seen 
indistinctly,  while  near  objects  are  clear;  the  latter  are  held 
closer  to  the  eye  than  they  should  be  and  fatigue,  pain,  or 
headache  follows.  If  these  patients  areexamined with  glasses, 
the  distant  vision  is  improved  or  made  perfect  by  the  use  of 
concave  glasses,  but  it  will  be  noticed  that,  while  a  weak  con- 
cave glass,  -^\  or  g'g,  makes  the  distant  vision  perfect,  they  can 
only  read  No.  1  at  six  or  eight  inches,  when  even  a  myope  of 
much  greater  degree  would  read  it  at  twelve  inches.  This 
should  excite  our  suspicions  and  on  an  examination  with  the 
ophthalmoscope  in  the  direct  method,  we  shall  find  that  the 
refraction  is  hyperopic,  astigmatic,  or  even  myopic ;  the  pupil  is 
often  much  contracted  in  these  cases  though  not  infrequently 
appearing  perfectly  normal. 

The  late  Dr.  AVoodyatt  called  the  attention  of  the  profession, 
some  years  ago,  to  the  fact  that  in  the  spastic  contraction  of 
the  ciliary  muscle,  astigmatism  became  apparent  and  was 
undoubtedly  due  to  an  irregular  action  of  certain  sets  of  the 
meridional  fibres  which  probably  cause  more  or  less  tilting  of 
the  lens.  I  have  repeatedly  verified  the  statements  then  made 
by  him  in  cases  in  my  own  practice,  and  have  seen  the  same 
good  results  follow  tlie  administration  of  Lilium  tig.  and 
Physostigma  in  causing  the  disappearance  of  the  apparent 
astigmatism. 

Causes. —Spasm  is  of  frequent  occurrence  in  children  who 
are  hyperopic  and  results  from  the  perpetual  strain  which  is 
occasioned  by  such  eyes.  In  older  persons  with  hyperopic 
refraction,  who  are  constantly  using  the  eyes  for  near  work  or 
fine  objects,  the  ciliary  muscle  gets  into  a  state  of  tonic  con- 
traction which  cannot  be  relaxed  at  the  -will  of  the  patient. 


800 


DISEASES  AND  INJURIES  OF  THE  EYE. 


An  emmetrope  may  induce  the  same  condition  by  prolonged 
use  of  the  eyes  for  near  work.  In  myopes  it  is  produced  by 
an  irritable  condition  of  the  eye  or  from  the  use  of  glasses 
■which  are  unnecessarily  strong.  It  also  arises  in  connection 
with  some  retinal  affections  or  is  the  accompaniment  of  chorea. 

Treatment. — Complete  rest  of  the  eyes  must  be  enforced, 
and  the  most  effective  treatment  consists  in  giving  the  ciliary 
muscles  rest  by  the  daily  use  of  atropine  solution  until  there 
is  a  complete  relaxation  of  the  spasm,  when  the  true  condition 
of  the  refraction  should  be  determined  and  the  necessary 
glasses  worn  constantly.  In  milder  cases,  rest  of  the  eyes 
from  near  work  and  the  use  of  such  remedies  as  Physostigma, 
Jaborandi,  Lilium  tig.,  or  Agaricus  will  relax  the  spasm  to 
such  a  degree  that  the  refractive  anomaly  can  be  determined 
and  corrected. 

PhysosUgma.  —  Particularly  serviceable  in  relaxing  the 
spasm  occurring  in  myopic  eyes;  the  book  is  brought  closer  to 
the  eyes  than  formerly  and  use  of  the  eyes  soon  becomes 
uncomfortable  or  impossible.  Twitching  of  the  eyeball  is 
often  present. 

Jaborandi. — More  useful  in  spasm  of  the  accommodation 
occurring  in  hyperopic,  myopic  or  astigmatic  patients.  The 
Tision  seems  to  disappear  temporarily  when  an  attempt  is 
made  to  look  at  fine  objects.  Moving  objects,  as  the  people 
or  teams  in  the  street,  occasion  headache,  vertigo  or  nausea. 

Agaricus. — Useful  in  spasm  of  the  ciliary  muscle  when 
accompanied  by  spasmodic  conditions  of  the  lids  or  ocular 
muscles. 

Lilium  tig. — Spasm  of  the  accommodation  in  light  degrees 
of  myopic  astigmatism,  when  cylindric  glasses  are  indicated 
and  yet  are  not  worn  with  comfort.  It  has  a  marked  effect  in 
relieving  the  asthenopic  symptoms  which  accompany  these 
cases  of  spasmodic  action  of  the  ciliary  muscle. 


CHAPTEE     XV. 
SYMPATHETIC    OPHTHALMIA. 

Under  the  general  term  sympathetic  ophthalmia  are  included 
^  ^  a  large  number  of  ocular  lesions  which  arise  in  one  eye  from 

disease  or  injury  of  the  other. 
^,  .  That  there  is  a  sympathy  existing  between  the  two  eyes  haa 

Icj  *  r  long  been  recognized.     It  may  be  observed  even  in  very  slight 
"external  affections,  as  when  the  presence  of    a  foreign  body 
upon  the  cornea  or  beneath  the  lid,  or  a  slight  attack  of  con- 
junctivitis in  one  eye,  excites  more  or  less  "fellow  suffering'* 
in  the  other. 

This,  however,  does  not  result  in  any  severe  diseased  condi- 
tion of  the  sympathizing  eye.  When  the  injury  is  more 
severe  or  affects  certain  regions  of  the  eye,  or  the  inflamma- 
tion is  more  deep-seated,  the  other  eye  may  take  on  a  very 
severe  inflammatory  condition. 

The  importance  of  sympathetic  diseases, .both  with  reference 
to  their  easy  recognition  and  proper  treatment,  can  hardly  be 
over-estimated  since  they  may  lead  to  an  impairment  of  the 
functions  of  the  eye  or  destruction  of  its  delicate  tissues  and 
loss  of  sight. 

Sympathetic  ophthalmia  is  commonly  divided  into  a  stage 
of  sympathetic  irritation,  when  there  is  only  functional  disturb- 
ance, and  one  of  sympathetic  inflammation,  when  a  destructive 
inflammatory  process  follows. 

Sympathetic  Irritation  is  practically  the  prodromal  stage 
of  sympathetic  inflammation,  but  it  may  also  appear  and  not 

301 


802 


DISEASES  AND  INJURIES  OF  THE  EYE. 


lead  to  that  dangerous  condition  of  which  it  is  commonly  the 
forerunner.  It  is  marked  by  a  paresis  of  the  accommodation 
•which  causes  difficulty  or  impossibility  of  accommodation. 
Any  attempt  to  use  the  eyes  for  near  work  is  followed  by 
lachrymation  and  congestion  of  the  eyeball  and  general 
irritable  appearance.  There  is  commonly  more  or  less  photo- 
phobia and  perhaps  some  contraction  of  the  visual  field,  flashes 
of  light  or  other  phosphenes,  and  frequent  and  temporary 
failure  of  the  vision.  These  symptoms  disappear  quickly  on 
the  removal  of  the  exciting  eye. 

Sympathetic  Inflammation. — The  most  frequent  form  of 
the  lesions  of  the  eye  which  are  included  under  the  general 
name  of  sympathetic  ophthalmia  is  that  of  sympathetic  iritis, 
or  irido-cyclitis,  yet  among  the  many  other  ocular  afiections 
which  are  superinduced  in  the  second  eye  after  disease  or 
injury  of  the  first,  are  ciliary  neuralgias,  irritation  and  inflam- 
mation of  the  optic  nerve  and  retina,  inflammation  of  the 
conjunctiva,  cornea,  and  choroid.  Glaucoma  and  diseases  of 
the  vitreous  and  the  lens  have  also  been  reported  as  arising 
from  the  transmitted  disease  tendency  of  the  injured  eye. 

The  ciliary  nerves,  which  are  believed  to  be  the  important 
agents  in  the  transmission  of  this  sympathetic  disturbance 
from  one  eye  to  the  other,  are  derived  from  the  ciliary  gang- 
Hon,  a  minute,  flattened  body  about  the  size  of  a  pin -head, 
situated  in  the  posterior  portion  of  the  orbit  between  the 
optic  nerve  and  the  external  rectus  muscle,  and  which  serves  as 
a  centre  for  the  supply  of  nerves,  motor,  sensory,  and  sympa- 
thetic, to  the  eyeball.  Its  roots  are  derived  from  the  fifth,  the 
third,  and  the  sympathetic  nerves;  while  from  its  fore  part 
proceed  the  ciliary  nerves,  some  fifteen  or  twenty  in  number, 
which  pierce  the  sclera  anterior  to  the  optic  nerve  entrance,  and 
run  forward  between  the  sclera  and  choroid,  after  further  subdi- 
vision, to  the  ciliary  muscle  in  which  they  form  a  fine  net-work 
from  which  the  cornea,  iris  and  ciliary  body  receive  their  nerve 
supply.  The  naso-ciliaris  nerve  which  gives  off  the  sensitive 
branch  of  the  fifth  to  the  ganglion  also  sends  two  or  three 
small  branches,  the  long  ciliary  nerves,  direct  to  the  sclera, 


SYMPATHETIC  OPHTHALMIA.  303 

which  pierce  it  near  the  entrance  of  the  short  ciliary  nerves 
and  pass  forward  to  the  ciliary  region  in  the  same  manner  as 
the  others.  This  bountiful  nerve  supply  of  the  ciliary  region, 
which  is  also  thus  brought  in  close  connection  with  all  other 
parts  of  the  eye,  renders  any  injury  or  disease  of  this  region 
of  the  utmost  importance  to  the  practitioner  from  the  fact  of 
the  danger  of  most  serious  complications  which  are  always 
imminent. 

The  channel  of  transmission  of  the  iafl.immation  from  one 
eye  to  the  other  can  not  be  said  to  be  invariably  the  same. 
Recent  researches  seem  to  have  settled  the  point  that  while 
the  sympathetic  invasion  is  in  many  cases  justly  attributed  to 
the  agency  of  the  sensitive  or  sympathetic  fibres  of  the  ciliary 
nerves,  yet  other  cases  arise  by  way  of  the  optic  nerves,  the 
blood-vessels  or  their  nerves,  and  the  lymph  tracts. 

Causes. — The  most  frequent  causes  of  sympathetic  inflam- 
mation are  injuries,  especially  in  the  cegioa  of  the  ciliary 
body;  irido-cyclitis ;  foreign  bodies  in  the  eye;  and  surgical 
operations  involving  the  iris  or  ciliary  body.  Displacements 
of  foreign  bodies  which  have  been  encysted,  contraction  of 
cicatrized  tissue,  bony  deposits  in  the  choroid,  or  the  wearing 
of  an  artificial  eye  upon  a  shrunken  stump  may  also  awaken 
the  dormant  tendency  to  sympathetic  inflammation.  Wounds 
likely  to  contract  during  the  process  of  healing,  and  irritating 
foreign  bodies  are  much  less  dangerous  when  they  occupy 
positions  beyond  the  ciliary  region.  The  danger  of  transmis- 
sion of  the  inflammation  after  the  injury  is  generally  greatest 
during  the  five  or  six  weeks  following  the  accident.  Yet  in 
one  case  I  have  seen  the  other  eye  affected  on  the  twelfth  day 
after  injury.  On  the  other  hand  years. may  elapse  before  any 
trouble  is  noticed.  In  one  case  I  have  noted,  thirty  years  had 
elapsed.  There  exists,  then,  no  period  when  danger  can  be  said 
to  have  disappeared,  as  after  twenty-five  or  thirty  years  an  eye 
has  become  destructive  of  its  fellow. 

As  a  rule  all  eyes  which  have  undergone  a  suppurative 
inflammation,  as  in  panophthalmitis,  are  not  likely  to  cause 
sympathetic  trouble,  owing  to  the  destruction  of  the  nerves 
which  results  from  the  suppurative  process. 


804  DISEASES  AND  INJUMIES  OF  THE  EYE. 

Symptoms. — Sympathetic  inflammation  may  commence  in- 
sidiously, or  burst  out  suddenly  without  the  slightest  hint  or 
warning  having  been  conveyed  either  by  fatigue  or  impair- 
ment of  the  accommodation  or  other  symptoms  as  photophobia 
and  ciliary  injection. 

On  the  other  hand  we  may  have  the  symptoms  of  weakened 
accommodation,  frequent  and  transitory  failure  of  visioii, 
photophobia  and  lachrymation,  and  general  complaint  of 
fatigue  of  the  eyes  with  inability  to  use  them ;  these  symp- 
toms have  already  been  spoken  of  as  those  of  sympathetic 
irritation,  which  may  exist  for  some  time  before  the  nerve 
destructive  process  follows,  or  they  may  be  the  immediate 
forerunners  of  the  most  dangerous  form  of  sympathetic 
inflammation. 

Sympathetic  ophthalmia  usually  assumes  the  form  of  a 
plastic  inflammation  of  the  iris  and  ciliary  body,  or  iris  and 
choroid.  There  is  in  4;his  inflammation  a  remarkable  tendency 
of  the  iris  through  this  plastic  effusion  to  become  adherent 
over  the  whole  extent  of  the  lens,  causing  complete  posterior 
synechia,  the  iris  becoming  thus  perfectly  immobile,  and  the 
pupil  frequently  filled  with  the  plastic  exudation.  The  tension 
of  the  eyeball,  which  early  in  the  attack  was  increased  by 
choking  up  of  the  channels  of  exit  at  the  corneal  junction, 
now  becomes  lessened  from  the  pressure  of  the  exudation 
upon  the  blood-vessels  causing  their  obliteration.  The  nutri- 
tion of  the  vitreous  and  lens  are  thus  interfered  with  and 
partial  or  complete  atrophy  of  the  eyeball  results. 

In  some  cases  the  sympathetic  inflammation  assumes  the 
form  of  a  serous  irido-choroiditis,  which  is  less  dangerous 
than  that  already  alluded  to,  but  unfortunately  it  usually 
passes  over  into  the  more  dangerous  type  of  adhesive  inflam- 
mation. The  tension  of  the  eyeball,  which  early  in  the 
disease  may  have  been  increased  by  pressure  of  the  mass  of 
exudation  upon  the  canals  of  exit  at  the  margin  of  the  cornea, 
now  becomes  reduced  owing  to  the  obliteration  of  a  consider- 
able number  of  vessels  in  the  most  vascular  region  of  the 
choroid  from  the  choking  process  resulting  from  the  interpo- 


SYMPATHETIC  OPHTHALMIA— DIAGNOSIS.  '  305 

sition  of  the  exudation  upon  and  around  the  vessels.  The 
nutrition  of  the  vitreous  humor  is  disturbed  and  its  trans- 
parency lost,  while  the  crystalline  lens  becomes  opaque,  and 
partial  or  complete  atrophy  of  the  eyeball  results. 

Diagnosis. — The  early  sympathetic  phenonema  in  the  more 
common  form  of  inflammation,  that  of  irido-cyclitis  plastica 
are,  intolerance  of  light,  ciliary  injection,  and  discoloration  of 
the  iris.  The  iris  exhibits  a  marked  tendency  to  become 
adherent  to  the  greater  part  or  whole  extent  of  the  lens, 
speedily  bringing  about  complete  posterior  synechia.  For  a 
short  time  the  pupil  appears  depressed,  but  soon  from  similar 
adhesions  between  the  ciliary  body  and  the  sclerotic  and  a 
movement  of  contraction  in  the  adherent  portions,  which 
depresses  tha  edge  of  the  lens,  the  anterior  chamber  becomes 
wider  toward  the  periphery,  while  the  pupil  advances  consid- 
erably nearer  to  the  posterior  surface  of  the  cornea.  If  to 
this  characteristic  appearance  be  added  an  immovable  and 
vascular  iris,  which,  owing  to  the  closure  of  the  pupil  by  the 
plastic  exudation  forms  an  extended  plane,  the  appearance 
will  be  so  remarkable  that,  without  any  history  of  the  case  a 
diagnosis  may  at  once  be  made. 

A  further  examination  will  doubtless  disclose  the  exciting 
cause  as  existing  in  the  other  eye. 

Pkognosis. — In  young  persons  the  atrophy  of  the  eyeball, 
resulting  from  obliteration  of  vessels  in  the  choroid,  may  be 
only  transitory  and  we  may  find  that  the  cornea  again  attains 
its  normal  curvature.  The  neoplastic  masses  undergo  such  a 
degree  of  atrophy  and  the  tissue  of  the  iris  becomes  so  thinned 
that  we  may  have  a  fair  pupil  resulting,  and  the  vitreous  may 
clear  up  so  that  we  are  enabled  to  examine  the  fundus  and  find 
that  the  inflammatory  process  has  extended  to  the  choroid, 
retina,  or  even  the  optic  nerve.  This  affords  sufficient  explana- 
tion of  the  reason  why  loss  of  vision  persists  in  spite  of  the 
general  improvement.  A  phthisical  condition  of  the  bulb 
or  atrophy  may  result  from  the  disturbance  of  its  nutrition. 

Treatment. — The  principal  object  of  all  treatment  should 
be  to  remove  as  speedily  as  possible  the  sympathetic  irritation 

20 


306  DISEASES  AND  INJURIES  OF  THE  EYE. 

by  enucleating  the  injured  eye,  as  nothing  is  gained  by  its 
removal  after  the  disease  has  become  one  of  sympatnetic 
inflammation. 

An  eye  which  contains  a  foreign  body  or  has  received  a 
serious  wound  of  the  ciliary  region  should  be  removed  early, 
unless  the  patient  is  constantly  under  surveillance  so  that  we 
may  be  able  to  remove  the  eye  at  the  moment  when  symptoms 
of  irritation  of  the  other  eye  appear. 

When  the  sympathetic  inflammation  has  involved  an  eye,  no 
operative  interference  is  of  any  value  beyond  that  which  may 
be  necessary  to  relieve  the  pain,  and  the  diseased  condition  is 
to  be  treated  as  already  described  for  irido-cyclitis.  When  it 
takes  other  forms,  as  that  of  iritis-serosa,  keratitis,  conjunc- 
tivitis, retinitis  or  neuritis,  the  destruction  of  the  eye  is  not  so 
rapid  and  the  removal  of  the  eye  even  when  the  disease  has 
become  well  marked  may  check  it  and  the  eye  be  not  seriously 
injured. 

While  it  seems  a  serious  matter  to  deprive  a  person  of  an 
eye,  which  may  be  neither  sightless  nor  painful,  yet  the 
knowledge  that  it  is  a  menace  to  its  fellow  and  may  sooner  or 
later  result  in  utter  loss  of  vision  of  the  other,  should  cause  us 
to  instruct  our  patient  of  the  extreme  danger  and  advise  its 
removal. 

The  danger  then  to  be  found  in  all  cases  of  severe  injury  to 
the  eyeball,  is  the  possibility  of  loss  of  the  remaining  eye 
through  the  transmission  of  sympathetic  ophthalmia.  Wiien 
this  inflammation  is  once  established  no  benefit  is  derived 
from  the  removal  of  the  injured  eye,  hence  it  should  be 
avoided  by  the  immediate  enucleation  when  symptoms  of  sym- 
pathetic irritation  appear.  If  the  injured  eye  has  already  lost 
all  vision  other  than  mere  perception  of  light,  and  contains  a 
foreign  body,  or  is  sensitive,  and  there  is  a  probability  of 
chalky  deposits  in  the  lens,  or  deposits  of  bony  tissue  in  the 
choroid,  or  if  the  atrophied  ball  is  sensitive  or  has  attacks  of 
inflammation  or  pain,  enucleation  is  imperative  at  once  unless 
the  patient  is  constantly  under  supervision  so  that  it  may  be 
removed  immediately  upon  tne  appearance  of  any  symptoms 
of  sympathetic  trouble. 


SYMPATHETIC  OPHTHALMIA— ENUCLEATION.  307 

The  operation  of  enucleation  is  accomplished  by  dividing 
the  conjunctiva  close  to  the  cornea  by  curved  scissors,  after 
the  patient  has  been  etherized,  and  the  speculum  introduced. 
.The  muscles  are  then  raised  upon  the  strabismus  hook,  di\aded 
close  to  the  sclera,  and  then  the  scissors  introduced  following 
the  convexity  of  the  eyeball  until  the  optic  nerve  is  reached 
and  divided;  the  ball  is  then  held  by  the  fingers  or  forceps, 
and  the  tissue  carefully  dissected  until  it  is  entirely  free  from 
the  socket;  the  orbit  is  then  sponged  with  cold  water  until  the 
hemorrhage  has  ceased,  a  wad  of  absorbent  cotton  placed  upon 
a  bit  of  soft  muslin  over  the  closed  lids,  and  a  compress  band- 
age applied  for  twelve  hours,  when  it  is  removed  and  the  orbit 
and  lids  kept  wet  by  a  decoction  of  calendula  flowers.  No 
pain  or  reaction  follows  in  cases  where  the  operation  is  care- 
fully performed,  and  the  orbit  is  usually  in  condition  to  wear 
an  artificial  eye  in  from  two  to  three  weeks. 

To  avoid  the  necessity  of  removal  of  the  eye  and  the  conse- 
quent use  of  an  artificial  one,  the  operations  of  optico-ciliary 
neurotomy  and  neurectomy  have  been  devised;  the  results, 
however,  have  not  so  far  been  sufficiently  conclusive  for  us  to 
advise  it  as  promising  the  advantages  claimed  for  it.  In  the 
three  cases  in  which  I  have  made  this  operation,  the  results 
have  not  been  satisfactory.  It  is  only  applicable  to  those  cases 
in  which  there  is  no  foreign  body,  deposit  of  bone,  or  growth 
in  the  eye,  and  when  the  eye  itself  presents  no  marked  deform- 
ity. The  dangers  are  from  hemorrhage,  or  orbital  cellulitis 
as  a  result  of  the  operation,  or  the  reunion  of  some  of  the 
nerves  afterwards,  and  a  recurrence  of  the  symptoms  of  sym- 
pathetic irritation. 

The  operation  of  neurotomy  is  performed  by  making  a  hori- 
zontal incision  in  the  conjunctiva  extending  from  the  cornea 
to  the  outer  canthus  and  the  external  rectus  muscle  divided  at 
the  insertion  of  its  tendon  after  having  secured  the  muscle  by 
a  thread ;  the  eyeball  is  then  forcibly  rotated  towards  the  inner 
canthus,  and  on  the  introduction  of  scissors  the  optic  nerve  is 
divided  and  the  eyeball  further  rotated  inward  until  the  ciliary 
nerves  are  brought  into  view  and  carefully  severed  at  their 


308  DISEASES  AND  INJURIES  OF  THE  EYE. 

entrance  into  the  sclera ;  having  thus  carefully  divided  all  of 
them,  the  eyeball  is  rotated  outward  into  position,  the  tendon 
of  the  external  rectus  muscle  is  united  by  a  stitch,  and  the 
conjunctiva  brought  together  by  another  suture,  and  the  pres-* 
sure  bandage  applied. 

The  operation  of  neurectomy  may  be  made  at  the  inner  can- 
thus  without  division  of  the  muscle,  by  making  an  incision  of 
the  conjunctiva,  between  the  internal  and  superior  recti  mufecles 
with  the  blunt  strabismus  scissors,  and  separating  the  tissue 
until  the  optic  nerve  is  reached  when  a  strabismus  hook  is 
introduced  and  the  optic  nerve  brought  into  view  in  the  incis- 
ion and  divided  as  far  back  as  possible;  the  portion  adherent 
to  the  sclera  is  then  seized  by  the  fixation  forceps,  and  the 
ciliary  nerves  carefully  divided  and  then  the  optic  nerve  is 
severed  close  to  the  sclera,  the  eyeball  rotated  into  position, 
the  wound  in  the  conjunctiva  closed  with  a  suture  and  the 
bandage  applied  as  in  the  former  operation.  The  hemorrhage 
and  prominence  of  the  eyeball  is  less  with  this  method  of 
operation  than  the  former  and  gives,  I  believe,  the  best  results. 

The  operation  for  enucleation  is  more  easily  performed  and 
much  safer  in  lessening  the  future  dangers  of  any  sympathetic 
trouble. 

USE  OF  AKTIFICIAL  EYES. 

An  artificial  eye  (Fig.  Ill)  is  a  hollow  hemispherical  shell 
of  enamel  which  is  so  colored  as  to  correspond  with  the  iris 
and  sclera  of  the  other  eye.     They  are  made 
"^  \^^k.     ^^  various  sizes  and  shapes  and  may  need  to 
^^    have  the  edges  notched  to  fit  irregularities 
FIG.  111.  in  special  cases. 

After  enucleation,  the  capsule  of  Tenon  with  the  muscles 
attached  is  left  to  form  a  cushion  upon  which  the  artificial  eya 
rests  and  thus  partakes  somewhat  of  the  movements  of  the 
sound  eye.  "When  the  contents  of  the  globe  are  evacuated  and 
the  sclera  left  the  motion  of  the  artificial  eye  is  better.  If 
much  of  the  contents  of  the  orbit  has  been  removed,  they  are 
of  little  use.     An  artificial   eye  may  also  be  worn  in  some 


USE  OF  ARTIFICIAL  EYES.  309 

cases  where  the  eye  has  been  lost  from  disease  or  injury, 
provided  that  the  cornea  has  been  destroyed  and  that  no 
foreign  body  is  retained  in  the  atrophied  ball  which  should  be 
neither  sensitive  nor  painful.  In  children  it  is  advisable  to 
insert  an  artificial  eye  which  is  to  be  worn  a  few  hours  each 
day,  in  all  cases  where  an  eye  has  been  removed  or  is  much 
atrophied,  as  the  arrest  of  development  of  the  orbit  and 
corresponding  side  of  the  face  is  materially  lessened. 

When  the  conjunctiva  has  been  extensively  removed  or 
destroyed,  or  the  membrane  atrophied  from  disease  or  presents 
cicatricial  bands,  the  conjunctival  sac  becomes  too  small  to 
retain  an  artificial  eye.  Occasionally  the  transplantation  of 
portions  of  the  conjunctiva  of  the  rabbit,  and  the  excision  of 
the  tendinous  bands  may  enable  us  to  insert  an  eye  with  good 
cosmetic  effect. 

Care  must  be  exercised  in  adapting  the  artificial  eye  to  the 
requirements  of  individual  cases,  and  the  eye  should  never  be 
so  large  as  to  prevent  the  closure  of  the  eyelids  over  it.  They 
should  not  be  so  large  as  to  press  upon  the  walls  of  the  orbit, 
and  should  have  a  notch  upon  the  upper  and  inner  edge  cor- 
responding to  the  supra-orbital  nerve  so  as  not  to  cause  any 
irritation  of  that  nerve  from  pressure.  Under  all  circum- 
stances the  artificial  eye  should  be  worn  with  perfect  comfort, 
and  should  not  be  inserted  for  three  or  four  weeks  after 
removal  of  the  eye,  or  until  all  inflammation  and  irritation 
have  disappeared. 

When  irritation  or  inflammation  arise  from  their  use,  or  the 
conjunctiva  becomes  granular,  they  must  be  laid  aside  and  the 
condition  relieved  by  treatment  when  they  may  be  again  worn. 
If  there  is  much  conjunctival  discharge,  the  eye  should  be 
examined  for  any  roughness  or  loss  of  smoothness  on  its 
surface  or  edges.  An  astringent  coUyrium  should  be  applied 
to  the  conjunctival  sac  until  the  irritation  is  removed,  and  if 
the  eye  is  found  defective  it  should  be  replaced  by  a  new  one. 

To  insert  an  artificial  eye  [proihesis  ociili)  the  upper  lid  is 
raised  by  the  fingers  of  one  hand,  and  the  upper  edge  of  the 
eye  which  has  been  previously  moistened  is  introduced  beneath 


310  DISEASES  AND  mJVRIES  OF  THE  EYE. 

it  and  the  lid  allowed  to  fall.  The  lower  lid  is  now  depressed 
Tintil  the  lower  edge  of  the  shell  is  pushed  into  the  lower 
palpebral  cul-de-sac,  when  the  eye  finds  its  proper  position. 
To  remove  it,  the  lower  lid  is  everted  and  the  thumb-nail  or 
the  head  of  a  hair-pin  is  introduced  under  the  lower  edge  of 
the  shell  which  is  slightly  pulled  forward  when  it  at  once  falls 
into  the  hand  held  to  receive  it  Should  it  fall  r^pon  a  hard 
surface  it  will  probably  be  broken.  Those  who  wear  artificial 
eyes  soon  acquire  the  knack  of  safe  and  easy  removal. 

The  eye  should  always  be  removed  at  night,  washed  gently 
in  water  and  carefully  dried,  when  it  should  be  placed  in  a 
small  box  containing  a  layer  of  cotton  until  the  following 
morning  demands  its  use. 

After  a  longer  or  shorter  time,  a  few  months  or  a  year  or 
two,  depending  upon  the  condition  of  the  conjunctiva,  the 
enamel  becomes  worn  and  rough  and  excites  a  conjunctival 
irritation  and  the  eye  must  be  replaced  by  a  new  one. 


CHAPTER    XVL 


DISEASES  OF  THE  LENS. 


ANATOMY. 

The  crystalline  lens  is  a  transparent,  solid  body,  of  a  double 
convex  shape  and  rounded  circumference.  lis  antero-posterior 
axis  measures  5  mm,,  and  its  diameter  from  8  to  9  mm.  It  is 
enclosed  in  a  transparent  elastic  membrane,  the  lens  capsule. 
The  anterior  surface  of  the  lens  is  in  contact  with  the  iris, 
which  rests  slightly  upon  it  towards  the  circumference.  The 
posterior  surface  is  more  convex  than  the  anterior  and  rests  in 
the  hollow  formed  for  it  in  the  vitreous.  It  is  composed  of 
flat,  hexagonal,  ribbon-like  plates  with  serrated  edges,  which 
are  held  together  by  cement  substance.  These  fibres  are  S- 
shaped  and  so  arranged  that  the  two  ends  are  brought  more  or 
less  close  together,  while  the  body  of  the  fibre  is  directed 
towards  the  circumference  of  the  lens. 

The  fibres  are  arranged  in  lamellae,  which  overlap  each 
other  and  form  three  triangular-shaped  sectors  with  basea 
towards  the  circumference  and  the  points  meeting  at  the  center 
of  the  lens.  During  infant  life  the  lens  is  more  globular  in 
shape,  while  in  adult  life  the  convexity  is  lessened,  until  in 
old  age  there  is  considerable  flattening  of  the  curvatures. 


312  DISEASES  AND  INJURIES  OF  THE  EYE. 

The  lens  does  not  present  the  same  density  tkrojighout,  the 
central  portion,  or  nucleus,  being  more  dense  than  the  outer 
or  cortical  portions,  which  are  soft  and  easily  detached  from 
the  nucleus.  In  the  adult  lens,  faint  white  lines  or  sutures 
are  seen  directed  from  the  poles  to  the  circumference ;  these 
are  usually  three  in  number,  but  may  be  more,  and  diverge 
from  each  other  like  rays,  those  of  the  two  surfaces  alternating. 
These  lines  become  apparent  during  life  in  some  cases  of 
cataract,  and  mark  the  place  of  intersection  of  the  fibres  in  the 
lamellar  segments. 

The  lens  capsule  is  a  perfectly  transparent,  homogeneous 
and  very  elastic  membrane,  permeable  to  fluids,  and  is  the 
medium  through  which  the  nutrition  of  the  lens  is  carried  on. 
Its  anterior  portion  is  about  twice  as  thick  as  the  posterior,  the 
latter  being  very  thin  at  the  posterior  pole.  The  circumfer- 
ence is  strengthened  by  the  added  fibres  of  the  suspensory 
ligament  of  the  zonule  of  Zinn. "  Upon  the  inner  surface  of  the 
anterior  portion  of  the  capsule  is  a  layer  of  columnar  endothe- 
lial cells  which  are  the  matrix  cells  from  which  the  lens  fibres 
are  developed,  and  in  adult  life  only  one  layer  of  cells  exists; 
this  undoubtedly  bears  a  close  relation  to  the  nutrition  of  the 
lens  fibres,  which  is  probably  carried  on  more  actively  from 
the  aqueous  chamber  than  the  vitreous.  The  capsule  is  very 
elastic,  and  rapidly  contracts  and  puckers  up  when  torn. 

The  zonule  of  Zinn,  after  it  leaves  the  ciliary  processes, 
splits  up  into  fibres  to  be  inserted  into  the  anterior,  and  partly 
into  the  posterior  surface  of  the  capsule  close  to  its  periphery, 
in  a  peculiar  zigzag  manner.  It  forms  with  the  hyaloid  the 
BO-called  canal  of  Petit. 

The  hardening  process,  which  the  Lens  undergoes  with  the 
advancement  of  age,  begins  in  the  nucleus  and  advances 
towards  the  cortical  substance,  and  this  density  when  obliquely 
illuminated,  gives  an  amber,  or  gray,  hue  to  this  portion  of  the 
lens.  The  function  of  the  lens  is  to  bring  the  rays,  with  the 
assistance  of  the  other  refracting  media,  to  a  focus  upon  the 
macula  lutea  of  the  retina,  and  hence  any  disturbance  of  its 
transparency  affects  the  vision. 


DISEASES  OF  THE  LENS— CATARACT.  313 

DISEASES  OF  THE  LENS 
CATAKACT. 

Cataract  is  the  term  applied  to  any  opacity  of  the  crystalline 
lens  or  its  capsule,  and  is  due  to  changes  in  the  structure  and 
composition  of  the  lens  fibres,  or  of  the  membrane  inclosing 
the  lens  from  proliferation  of  its  endothelium  or  exudative 
deposits  derived  from  neighboring  tissues.  The  pathology  of 
cataract  varies  with  the  causes  which  produce  it,  and  consists 
of  fatty  degeneration  or  sclerosis  of  the  lens  fibres,  or  swelling 
of  the  lens  fibres  from  the  inhibition  of  fluid. 

Varieties. — Cataracts  may  be  divided  into  those  where  the 
opacity  is  situated  in  the  lens,  lenticular  cataracts,  or  in  the 
capsule,  capsular  cataracts.  Lenticular  cataracts  are  again 
classified  according  to  the  consistency  of  the  lens  into  hard, 
soft,  or  mixed;  according  to  condition  into  simple,  complicated, 
stationary  and  progressive;  according  to  the  stage  of  the 
cataract  into  incipient,  imm,ature,  ripe,  hypermature  and  de- 
generated. 

Causes. — The  causes  of  cataract,  excluding  traumatic  and 
capsular  cataract,  are  still  obscure  and  a  matter  of  doubt  and 
speculation.  It  appears  most  probable,  as  the  lens  depends 
for  its  nutrition  upon  the  vitreous  and  aqueous  humor,  that 
any  alteration  or  interference  with  its  nutrition  tends  to  render 
it  opaque,  and  these  morbid  alterations  in  the  condition  of  the 
Titreous  or  aqueous  may  depend  upon  local  or  constitutional 
causes.  Among  the  local  causes  may  be  cited  injuries  to  the 
eyeball,  lens  or  its  capsule,  and  inflammatory  diseases  of  the 
interior  portions  of  the  eye.  Of  the  more  remote  causes, 
rheumatic  affections,  syphilis,  struma  and  sclerosis  of  the 
arterial  coats.  The  changes  in  the  lens  may  be  induced  by 
senile  changes,  alterations  in  the  blood,  or  may  arise  from 
defective  innervation. 

The  causes,  however,  vary  with  the  individual,  and  there  is 
no  single  cause  which  will  comprehend  all  cases  of  cataract. 
Dr.  Burnett,  of  London,  has  called  our  attention  to  the  effect 
of  the  excessive  use  of  sugar,  salt  and  calcareous  waters  as 


314 


DISEASES  AND  INJURIES  OF  THE  EYE. 


productive  of  cataract,  and  to  this  I  would  add  the  saturation 
of  the  blood  with  stimulants  and  narcotics  as  undoubtedly 
interfering  w*ith  the  proper  nutrition  of  the  lens. 

Symptoms. — There  is  usually  slowly  developed  dimness  of 
sight,  distant  objects  lose  their  clearness,  and  near  objects 
must  be  held  closer  to  the  eye.  The  vision  is  improved  by 
turning  the  back  to  the  light,  or  shading  the  eyes  with  the 
hand.  The  patient  thinks  that  a  change  of  glasses  is  neces- 
sary but  finds  nothing  that  will  improve  the  vision,  or  the 
vision  may  be  temporarily  improved  by  concave  glasses  owing 
to  the  swelling  of  the  lens.  He  may  also  find  the  vision 
improved  by  tinted  glasses  which  will  dilate  the  pupil  by 
lessening  the  amount  of  light  admitted  to  the  eye.  The  vision 
is  usually  better  in  a  dim  light,  or  in  the  evening,  rather  than 
during  the  day.  Again,  the  gas  jet  or  lamp  flame  may  have  a 
peculiar  irradiation.  This  is  not  to  be  confounded  with  the 
rainbow  colors  seen  in  cases  of  glaucoma.  There  is  rarely  any 
pain,  but  specks  before  the  eyes  and  phosphenes  are  not 
infrequently  complained  of. 

The  objective  symptoms  consist  in  a  grayish  or  whitish 
appearance  of  the  pupil,  which  is  usually  contracted.  The 
behavior  of  the  pupil  is  of  importance;  if  it  is  contracted 
and  does  not  dilate  rapidly  under  atropine  it  indicates  an  unfa- 
vorable prognosis  for  extraction  of  the  lens.  The  field  of 
vision  in  simple  cataract  is  good  and  the  patient  quickly 
notices  any  variation  in  the  light. 

Diagnosis. — While  the  diagnosis  of  cataract  is  not  attended 
with  much  difl&culty,  we  must  at  the  time  of  the  examination 
consider  the  location,  extent  and  character  of  the  opacity  and 
also  whether  it  is  simple  or  complicated. 

If  the  opacity  is  dense,  it  is  readily  recognized  from  the 
whitish  or  gray  appearance  of  the  pupil. 

Opacities  of  the  cornea  must  not  be  confounded  with  cata- 
ract, and  when  oblique  illumination  is  used,  the  lenticular 
opacity  -wall  be  seen  behind  the  pupil.  If  the  pupil  is  con- 
tracted, or  if  the  opacity  lies  more  towards  the  periphery  of 
the  lens,  it  will  be  necessary  to  dilate  the  iris  with  atropine  to 


LENTICULAR  CATARACT.  315 

fully  define  its  cliaracter  and  extent.  The  smoky  hue  of  the 
lens  which  comes  from  age  and  which  is  often  associated  with, 
glaucoma,  is  not  to  be  mistaken  for  true  cataract;  here  the  use 
of  the  ophthalmoscope,  with  a  feeble  illumination,  will,  when  it 
is  held  ten  or  twelve  inches  from  the  eye,  and  the  reflected 
light  thrown  somewhat  obliquely  from  various  points  across 
the  pupil,  enable  us  to  obtain  a  red  reflex,  and,  at  the  same 
time,  discover  any  real  opacities  which  may  be  present,  and 
which  will  appear  black  instead  of  gray  when  examined  in. 
this  manner. 

LENTICULAR   CATARACT. 

Cataracts  affecting  the  lens  fibres  may  be  considered  under 
four  heads:  the  soft,  zonular,  cortical  or  mixed,  and  senile  or 
hard. 

SOFT  CATARACT. 

Soft  cataract  occurs  under  thirty  years  of  age  and  is  termed 
soft,  because  the  nucleus  up  to  that  age  has  not  acquired 
sufiicient  hardness  to  necessitate  its  consideration  in  the  selec- 
tion of  an  operation  for  the  removal  of  cataract. 

Causes. — It  may  be  congenital,  but  more  commonly  results 
from  injury  to  the  eyeball,  as  punctured  wounds  of  the  lens  or 
rupture  of  its  capsule  from  blows,  and  sudden  compression  of 
the  globe.  It  also  arises  as  the  result  of  certain  inflammatory 
diseases  of  the  choroid  or  retina  which  involve  the  vitreous 
and  thus  impair  the  nutrition  of  the  lens. 

Diagnosis. — It  is  hardly  possible  to  mistake  this  form  of 
cararact,    as  the  pupil  presents  a  bluish 
white  or  pearly  appearance,  and  when  the 
iris    has  been  dilated  with    atropine  the 
FIG.  112.  whole  lens  appears  like  a  little  sac  filled 

with  a  milky  substance,  as  in  Fig.  112; 
now  and  then  more  opaque  or  chalky 
looking  spots,  or  the  sparkle  of  choles- 
terine  crystals  may  be  seen  in  it,  as  in  ^^^-  ^^^• 

Fig.  113.  With  the  focal  illumination  or  with  the  ophthalmo- 
scope the  opacity  is  seen  to  involve  the  whole  lens. 


316,  DISEASES  AND  INJURIES  OF  THE  EYE. 

In  some  cases  of  traumatic  cataract,  masses  of  the  lens  sub- 
stance may  be  found  extending  into  the  anterior  chamber  as  a 
gelatinous  mass,  or  the  whole  lens  may  be  swollen  and  press- 
ing forward  upon  the  iris. 

Prognosis. — Congenital  cataracts  give  good  results  as  far  as 
surgical  procedure  is  concerned,  but  as  they  are  often  the 
result  of  arrest  of  development,  the  gain  of  sight  is  uncertain, 
because  of  the  imperfect  development  of  other  portions  of  the 
eye.  It  sometimes  happens  that  the  disintegrated  lens  sub- 
stance is  gradually  absorbed  and  the  shrunk  and  wrinkled 
opaque  capsule,  containing  perhaps  some  chalky  deposits, 
appears  as  an  opaque  membrane  situated  in  the  pupil  slightly 
behind  the  iris,  constituting  in  this  case  a  capsular  cataract. 

The  prognosis  of  the  traumatic  variety  will  depend  upon 
the  extent  and  nature  of  the  injury,  and  the  presence  or 
absence  of  a  foreign  body  in  the  lens  or  eyeball.  When  the 
cataract  is  complicated  by  other  diseases  of  the  eye  the  pros- 
pect of  vision  depends  upon  the  nature  of  the  complication, 
which  also  increases  the  surgical  dangers. 

Treatment. — The  treatment  of  these  cases  is  purely  surgi- 
cal, and  two  operations,  those  of  discission  and  extraction, 
through  an  incision  in  the  cornea,  are  used.  In  all  cases  of 
cataract  occurring  under  thirty  years  of  age  the  whole  lens 
substance  may  be  made  to  become  absorbed  by  an  operation 
which  punctures  the  capsule  and  breaks  up  the  lens  fibres.  In 
congenital  cataract  the  operation  should  be  made  as  soon  after 
birth  as  possible,  as  the  best  results  as  to  vision  are  obtained 
Avhen  the  operation  has  not  been  delayed  beyond  a  few  months 
after  the  birth  of  the  child. 

Operation  of  Discission. — The  operation  for  solution  or 
absorption  of  the  cataract  (Fig.  114)  is  performed  in  the 
following  manner.  The  pain  from  the  operation  is  not  sufl&- 
cient  to  necessitate  the  use  of  an  anaesthetic,  except  in  young 
children.  The  pupil  must  be  fully  dilated  with  atropine  and 
the  patient  placed  in  a  recumbent  position  on  an  operating 
chair,  or  suitable  sofa,  before  a  good  light.  The  eyelids  are 
then  separated  by  a  speculum  and  a  needle  with  a  stop  shoulder 


OPERATION  OF  DISCISSION. 


317 


Tia.  114. 


is  introduced  a  lina  ia  front  of  the  sclerotic  margin  of  the 
cornea,  on  its  inner  side,  passed  over  the  edge  of  the  dilated 
pupil  until  the  point  rests  upon  the  lens ;  a  second  needle  is 
then  introduced  at  the  opposite  point  of  the  cornea  until  it 
also  rests  upon  the  centre  of  the  anterior  surface  of  the  lens ;, 

the  capsule  of  the 
lens  is  then  care- 
fully torn  through 
and  the  needles  by 
a  gentle  drilling 
motion  made  to 
slightly  enter  the 
cortical  lens  sub- 
stance. No  pres- 
sure is  to  be  made 
upon  the  lens,  as  it 
may  be  depressed 
into  the  vitreous,  or  injury  to  the  ciliary  body  result  from 
the  tension  of  the  zonule.  The  needles  are  now  simultaneously 
withdrawn.  The  aqueous  finds  its  way  into  the  lens,  which 
swells  up  and  undergoes  absorption.  This  process  requires 
several  weeks  and  the  operation  will  probably  have  to  be  re- 
peated at  intervals  of  six  or  eight  weeks  until  the  whole  lens 
is  absorbed. 

The  after  treatment,  if  no  complications  occur,  is  very 
simple.  The  eye  is  bandaged,  atropine  instilled  sufficiently 
often  to  keep  the  pupil  fully  dilated,  and  the  patient  kept 
quiet  for  a  few  days  until  all  irritation  resulting  from  the 
operation  has  disappeared.  The  pupil  should  be  kept  well 
dilated  during  the  periods  intervening  between  the  succeeding 
operations,  and  the  eyes  protected  from  strong  liglit. 

The  dangers  of  the  operation  are,  first,  the  swollen  lens  may 
cause  an  increased  tension  which  may  be  rapidly  destructive 
of  vision.  This  arises  from  the  too  extensive  rupture  of  the 
lens  capsule,  or  from  the  efibrt  to  accomplish  too  much  at  the 
first  operation,  and  probably  from  other  causes  which  are  not 
within  the  knowledge  or  control  of  the  surgeon.     If  such  a 


318  DISEASES  AND  INJURIES  OP  THE  EYE. 

complication  should  occur,  an  iridectomy  must  be  made  without 
delay,  and  the  operation  of  linear  extraction  should  be  com- 
pleted. Secondly,  the  swollen  lens,  or  portions  of  it  which 
have  escaped  into  the  anterior  chamber,  may  press  upon  the 
iris  and  set  up  iritis,  or  if  the  ciliary  body  has  been  interfered 
with  by  pressure  upon  the  lens  during  the  operation,  an  irido- 
cyclitis may  arise.  In  such  a  case,  the  softened  lens  must  be 
removed  at  once  by  linear  extraction.  Care  must  be  taken  not 
to  rupture  the  posterior  capsule  with  the  needles,  or  the 
vitreous  will  mix  with  the  lens  substance  and  prevent  its 
absorption. 

The  danger  of  the  operation  is  least  in  young  children  and 
when  the  whole  lens  substance  is  softened  down.  It  is  greatly 
increased  if  the  margin  of  the  lens  is  transparent. 

Opebation  for  Linear  Extraction. — (Fig.  115).     This 


FIG.  115. 

procedure  is  performed  as  follows:  A  needle  operation,  as 
just  described,  is  usually  performed  first  and  may  precede  the 
extraction  several  days.  If  the  lens  is  fluid  this  may  be  dis- 
pensed with.  The  preparation  of  the  patient  is  the  same  as 
that  for  discission.  An  incision  is  made  with  a  broad  needle, 
or  a  keratome,  about  a  line  from  the  sclerotic  margin  of  the 
cornea,  and  two  and  a  half  or  three  lines  in  breadth.  A 
cystotome  is  then  introduced  into  the  anterior  chamber,  and 
the  capsule  ruptured  in  a  line  parallel  to  the  incision  in  the 
cornea.  Slight  pressure  upon  the  lower  edge  of  the  cornea 
with  a  curette  may  now  be  sufficient  to  cause  the  lens  matter 
to  flow  out,  or  a  narrow  curette  or  spatula  is  introduced  into 


ZONULAR  CATARACT.  319 

the  wound  (Fig.  116)  and  the  lens  substance  allowed  to 
flow  out  beside  it. 

The  after  treatment  consists  of  rest  in  bed,  a  bandage  and 
the  instillation  of  atropine,  together  with  the  controlling  of 
any  reaction  which  may  arise,  by  Aconite,  Arnica,  or  Calen- 
dula, and  cold  applications. 

The  Operation  of  Removal  by  Suction  is  applicable  only 
when  the  lens  matter  is  in  a  fluid  state  and  may  be  employed 
after  the  needle  operation  has  rendered  the  lens  very  soft. 
The  procedure  is  the  same  as  for  linear  extraction,  except  that 


riG.  116. 
after  the  capsule  has  been  ruptured,  the  point  of  a  suction 
instrument  is  introduced  into  the  lens  and  the  pulpy  or  fluid 
matter  is  drawn  into  the  tube  of  the  instrument,  until  the 
pupil  is  clear.  Care  must  be  exercised  to  prevent  a  portion  of 
the  iris  from  being  drawn  into  the  instrument. 

The  advantages  of  these  two  methods  over  the  simple 
needle  operation  is  that  time  is  saved,  and  the  result  of  the 
operation,  if  successful,  is  at  once  more  apparent  and  brilliant. 
While  the  needle  operation  is  much  slower  in  its  results,  the 
operation  often  requiring  several  repetitions,  yet  it  is  much 
the  safer  proceeding. 

After  either  of  these  operations,  a  portion  of  the  opaque 
capsule  may  remain ;  this  must  be  treated  at  a  later  period  by 
another  needle  operation  as  will  be  described  under  the  oper- 
ations for  capsular  secondary  cataract 

ZONULAR  CATARACT. 

Zonular  cataract  is  a  variety  of  cataract  in  which  a  layer  or 

§zone  of  the  cortical  substance  (Fig.  117)   giarround- 
ing  the  nucleus  is  opaque  while  the  remaining  por- 
tions are  perfectly  transparent.     At  times,  several 
riG.  117.      of  these  layers  are  affected  and  the  nucleus  also. 


320 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Causes. — It  is  generally  cougenital,  but  may  be  formed 
during  the  first  few  months  of  life,  and  may  depend  upon 
hereditary  syphilis  or  infantile  convulsions. 

Symptoms. — During  the  early  period  of  the  child's  life, 
opacities  of  the  lens  may  be  overlooked,  as  defective  vision 
may  not  be  apparent  until  the  child  is  about  two  years  of  age, 
when  he  begins  to  use  the  eyes  for  near  objects.  He  may 
even  then,  owing  to  the  natural  largeness  of  the  pupil,  see 
tolerably  well ;  later,  however,  if  the  opacity  encroaches  upon, 
the  pupil  the  impaired  vision  is  complained  of.  In  many 
cases  the  vision  is  very  defective  and  is  frequently  associated 
with,  and  may  be  the  cause  of,  nystagmus. 

Diagnosis.  —  The  opacity  appears   as  a  whitish-gray  film, 
more  commonly  in  the    posterior  cortical  layers,  and  hence 
some  distance  behind  the  pupil.     When  the  pupil  is  dilated 
with  atropine  and  the  lens  examined  by  focal  illumination 
(Fig.  118),  the  opacity  will  be  found  to 
encircle  the  nucleus,  or  the  latter  is  itself 
opaque  and  whitish  and  with  bundles  of 
FIG.  118.  opaque  lens  fibres  extending  out  from  it- 

into  the  clear  remaining  tissue.  With 
the  ophthalmoscope  {Fig.  119)  these 
opacities  appear  as  dark  rings  or  spots 
upon  the  red  back -ground  of  the  fundus.  ^^'^-  ii^- 

Prognosis.  —  With  very  few  exceptions  these  opacities 
remain  stationary,  the  lenticular  opacity  is  well  defined,  small, 
and  the  circumference  of  the  lens  clear.  If,  however,  in 
addition  to  the  central  or  peripheral  opacity  there  are  also 
small  dots  or  streaks  in  the  cortical  substance,  the  cataract  is 
apt  to  become  progressive. 

Treatment. — If  the  vision  is  fair,  or  when  the  opacity  is 
not  central,  patients  occasionally  derive  considerable  improva- 
ment  from  the  use  of  atropine,  which  keeps  the  pupils  dilated 
and  the  vision  is  made  temporarily  better  while  its  action 
is  kept  up.  If  the  periphery  is  clear,  a  small  iridectomy  may 
be  made  at  the  inner  and  lower  portion  of  the  iris  with  very 
satisfactory  results.     If  the  opacity  is  central  and  dense,  or  is- 


CORTICAL  OR  MIXED  CATARACT.  321 

progressive,  the  lens  may  be  extracted,  or  removed  by  the 
more  tedious  process  of  discission. 

CORTICAL  OR   MIXED   CATARACT. 

Cortical  or  mixed  cataract  is  characterized  by  the 
appearance  of  opaque  bundles  of  fibres,  or  striae,  in  the  cortex 

/\      (Fig.  120),  which  commence  at  the  circumference  of  the 

u|]      lens  and  converge  toward  the  centre.     The  striae  may 

\y      appear  in  the  anterior,  but  more  often  in  the  posterior 

FIG.  120.  layers  of  the  lens.     These  striae  in  young  people  are 

white,  pearly,  and  broad,  and  progress  rapidly. 

The  term  is  also  applied  to  that  class  of  cases  where  the 
nucleus  has  become  hard,  as  after  forty  years  of  age,  when  the 
cortical  substance  becdmes  opaque  and  the  nucleus  is  involved 
later. 

Causes. — When  occurring  under  thirty-five  or  forty  years 
of  age,  injuries  of  the  eye  and  diseases  of  the  interior  struc- 
tures by  interfering  with  the  nutrition  of  the  lens  are  the 
exciting  causes.  When  appearing  later  it  is  due  to  mal- 
nutrition or  senile  changes. 

Symptoms  and  Diagnosis. — The  vision  is  lessened  accord- 
ing to  the  amount  and  density  of  the  opacity.  The  striae  are 
fully  seen  when  the  pupil  is  dilated,  and  when  the  cataract  has 

MG.  121.  tends    up    to    the  fig.  122. 

capsule,  and  the  iris,  when  not  dilated,  is  observed  lying 
immediately  upon  the  opaque  lens.  When  examined  by  the 
ophthalmoscope  the  strias  appear  as  dark  lines  as  in  Fig.  121, 
and  when  focal  illumination  is  employed  the  streaks  present  a 
lightish  appearance  as  in  Fig.  122. 

Treatment. — When  the  cataract  is  in  an  incipient  stage, 

and  when  arising  from  constitutional  enfeeblement,  or  diseased 

conditions  of  the  interior  tissues  of  the  eye,  the  progress  may 

be  stayed  by  the  use  of  such  remedies  as  improve  the  general. 

21 


322  DISEASES  AND  INJURIES  OF  THE  EYE. 

condition  of  the  blood  and  arrest  the  other  local  changes  in  the 
eye.  When  fully  formed,  and  operative  measures  are  desirable, 
the  methods  to  be  adopted  for  the  removal  of  the  cataract  will 
depend  upon  the  age  of  the  patient;  if  under  thirty,  the 
operation  for  soft  cataract  will  be  indicated ;  if  over  this  age, 
or  after  forty,  tho  nucleus  has  become  so  hardened  that  the 
operation  to  be  described  for  senile  cataract  will  be  necessary. 

HARD  OR   SENILE  CATARACT. 

This  is  the  most  frequent  and  important  variety  of  cataract. 

It  is  called  hard,  because  it  occurs  late  in  life  when  the  nucleus 

has  become  dense  and  hard,  and  the  loss  of   transparency  is 

^         frequently  situated  in  this  portion  of  the  lens  (Fig. 

[■]        123) ;  it  is  called  senile,  ffom  the  fact  that  it  is 

\)         usually  associated  with  other  changes  in  the  tissues 

riG.  12a     which  result  from  advanced  age. 

Causes.  —  As  persons  advance  in  life  senile  changes  take 
place  in  the  lens  by  which  its  nucleus  is  rendered  amber-col- 
ored, or  smoky,  and  yet  good  sight  is  retained;  this  is  not 
considered  cataract,  but  these  degenerative  changes  may 
advance  still  further  and  the  process  of  osmosis  becomes  more 
difficult  and  the  lens  tissue  opaque.  The  nutrition  of  the  lens 
not  being  directly  derived  from  blood-vessels,  the  condition  of 
the  lens  from  hardening  of  its  texture  is  such  that  the  circula- 
tion of  the  lymph  through  it  is  not  sufficiently  rapid  to  maintain 
the  proper  nourishment  of  the  lens  fibres,  and  the  nucleus 
which  is  still  further  removed  from  the  sources  of  supply, 
sufifers  and  the  immediate  effect  is  loss  of  transparency,  while 
later,  there  is  a  degeneration  and  a  retrograde  metamorphosis. 
Again,  these  changes  may  result  from  an  interference  with  the 
circulation  of  the  lymph  currents  in  the  vitreous,  from  local 
changes  in  the  nutrient  membranes  of  the  eye,  the  choroid,  or 
from  an  impoverished  condition  of  the  blood  itself.  We  have 
in  short,  then,  primarily,  the  lessened  power  of  the  lens  to 
carry  on  its  own  nutritive  processes,  and  secondly,  an  interfer- 
ence with  its  nutrition  by  causes  not  resident  in  the  lens  itself, 


HARD  OR  SENILE  CATARACT.  323 

and  particularly  the  want  of  proper  nutrient  elements  in  the 
blood  supply  of  the  eyeball.  Undoubtedly  the  saturation  of 
the  blood  with  certain  matters,  as  urea,  sugar,  salt,  calcareous 
matters,  or  the  retention  of  waste  material  in  it  in  patients 
who  use  alcohol,  tea,  or  caffee  to  excess,  is  sufficient  to  account 
for  the  loss  of  transparency. 

Symptoms. — In  senile  cataract,  the  subjective  symptom  is 
commonly  progressive  dimness  of  sight,  which  induces  fre- 
quent changes  of  glasses,  in  order  to  bring  objects  closer  to 
the  eye  to  obtain  a  larger  retinal  image.  The  vision  is  foggy, 
or  the  patient  is  annoyed  by  the  distortion  of  the  light  or 
from  shadows  thrown  upon  the  retina  by  irregularities  in  the 
opacity.  Sometimes  the  patient  finds  his  vision  improved  by 
concave  glasses  where  previously  convex  glasses  were  worn; 
this  is  explained  on  the  ground  that,  in  the  incipient  stage  of 
cataract,  the  lens  becomes  swollen  and  a  mild  form  of  myopia 
is  temporarily  acquired.  There  is  rarely  any  pain  or  other 
disturbances  complained  of,  in  or  about  the  eye. 

Diagnosis.  —  When  the  cataract  is  in  an  incipient  stage 
some  difficulty  may  be  experienced  in  diagnosing  the  condi- 
tion,   as  the   pupil  may  appear    black  and    nothing  may  be 
observable   but    the    amber   hue   of    the 
nucleus  which  is  seen  by  focal  illumin- 
ation; dilating  the    pupil,    however,  will 
riQ.  124.  probably  reveal  striae  or  grayish  streaks 

extending  from  the  periphery  towards  the  pupil,  which  indicate 
changes  in  the  cortical  substance.  With  the  ophthalmoscope, 
in  this  case,  we  may  be  still  able  to 
distinguish  the  details  of  the  fundus 
fairly  well,  if  the  other  media  are  clear. 
As  the    opacity    increases,  the  diagnosis  fig.  125. 

becomes  more  easy,  as  the  pupil  takes  on  a  yellowish, 
deep-seated  haze,  on  which  a  shadow  is  cast  by  the  iria 
on  the  side  from  which  the  light  comes,  as  in  Fig.  124. 
If  now,  the  light  is  reflected  into  the  eye  with  the  ophthalmo- 
scopic mirror,  the  centre  of  the  pupil  appears  dark,  while 
around  this  dark  blur  a  circular  ring  of  red  reflex  will  be  ob- 
served, as  in  Fig.  125. 


324 


DISEASES  AND  INJURIES  OF  THE  EYE. 


If  the  cortical  changes  are  very  marked  the  striae  will 
appear  white  or  grayish,  as  in  Fig.  122,  by  focal  illumination, 
and  dark  or  black  as  in  Fig.  121,  when  the  ophthalmoscope  ia 
used,  and  if  the  intervening  substance  is  clear  a  red  reflex, 
with  dark  streaks  is  obtained  and  portions  of  the  fundus 
possibly  observed.  If  the  cataract  is  far  advanced  and  the 
opacity  dense,  no  difficulty  will  be  experienced  in  diagnosing- 
the  condition,  as  the  pupil  no  longer  appears  dark  but  grayish^ 
and  the  opacity  will  be  discovered  behind  the  pupillary  space. 
Having  diagnosed  the  presence  of  cataract  we  must  also  know 
the  condition,  whether  unripe  or  immature,  ripe  or  mature,  or 
over-ripe,  degenerated,  or  hyper-mature. 

An  immature  cataract  is  one  in  which  the  opacity  is  not 
complete,  and  with  focal  illumination  a  shadow  will  be  thrown 
upon  the  lens  by  the  iris,  showing  that  there  is  still  some 
cortical  portion  of  the  lens  between  the  iris  and  nucleus  whick 
has  not  become  opaque  and  hard.  The  depth  of  this  shadow 
will  also  enable  us  to  judge  of  the  amount  of  lens  which  still 
remains  to  be  changed  before  the  cataract  becomes  mature;  if 
the  shadow  is  very  narrow,  there  is  less  lens  substance  to  be 
changed  than  when  it  is  broad. 

A  mature  cataract  is  distinguished  by  complete  opacity,  the 
absence  of  any  reflex  from  the  interior  of  the  eye  when  the 
mirror  is  used,  and  the  edge  of  the  iris  appearing  to  lie 
directly  upon  the  lens,  no  shadow  being  thrown  on  the  cataract 
by  the  pupillary  margin. 

When  a  cataract  has  existed  for  years  it  degenerates  and  i» 
termed  hyper-mature.  The  outer  layers  of  the  cortical  sub- 
stance become  semi-fluid  and  a  granular  mass  with  fat  globules 
and  cholesterine  crystals  is  observed  while  the  hard,  yellow 
nucleus  is  found  partially  below  the  pupil  in  the  lens  capsule^ 
and  may  be  seen  to  change  its  position  with  the  movements  of 
the  head.  This  condition  has  been  termed  Morgagnian 
cataract. 

The  capsule  may  also  show  degenerative  changes,  and,  at 
times,  deposits  of  calcareous  matters  are  seen.  Sometimes 
the  lens  appears  of  a  dark  brown  color  and  there  are  no  other 


HARD  OR  SENILE  CATARACT.  325 

opacities  present ;  the  cataract  is  then  called  black  or  caiaracta 
nigra. 

In  the  examination  of  the  cataract  its  size  should  also  be 
noticed,  as  it  has  great  significance,  both  as  indicating  the 
condition  of  the  cataract  and  also  having  a  bearing  in  regard 
to  the  operation.  When  the  cataract  is  immature  it  is  larger 
ihan  when  mature,  as  in  the  incipient  stage  the  lens  becomes 
more  bulky  from  an  increase  of  its  watery  elements,  which 
are  diminished  as  the  cataract  becomes  ripe.  Cataracts  which 
form  slowly  are  usually  of  less  size  than  those  which  grow 
rapidly.  A  large  cataract  is  usually  present  when  the  iris  is 
pressed  forward  and  the  pupil  reacts  slowly,  while  if  the 
surface  of  the  iris  is  flat  the  cataract  is  smaller. 

Prognosis. — The  prognosis  of  cataract  includes  the  rapidity 
of  its  progress,  its  complications,  its  possible  remedial  relief, 
its  removal  by  extraction  and  the  subsequent  prospective 
recovery  of  vision.  Opacities  of  the  lens  which  are  developed 
in  elderly  persons  increase  until  the  whole  lens  substance 
becomes  opaque,  but  the  rate  of  progress  varies  greatly  in 
individual  cases,  and  depends  very  much  upon  the  existence  of 
the  conditions  which  have  primarily  caused  the  opacity.  As 
long  as  the  nucleus  alone  is  affected,  the  progress  is  very 
slow,  and  may  remain  stationary  for  a  long  time  if  the  general 
nutrition  of  the  eye  is  directly  or  indirectly  improved.  "When 
the  cortex  becomes  involved  the  progress  towards  complete 
opacity  becomos  more  rapid,  and  the  time  consumed  in  the 
process  will  vary  from  a  few  months  to  several  years.  When 
the  striaB  are  broad  the  progress  is  commonly  more  rapid  than 
when  they  are  narrow.  It  may  be  possible,  by  the  observance 
of  proper  hygienic  measures  and  the  use  of  remedies,  to  stop 
the  increase  of  the  striae  and  retain  the  vision  of  the  patient 
for  a  long  time.  In  general,  the  condition  of  the  patient,  as 
well  as  that  of  the  eye,  has  much  to  do  with  the  progress  of 
the  cataract. 

When  the  cataract  is  simple,  that  is  when  there  is  no  dis- 
coverable lesion  of  the  eye  which  produces  it,  the  prognosis  as 
regards  the  vision  after  its  extraction  is,  other  things  being; 


326 


DISEASES  AND  INJURIES  OF  THE  EYE. 


equal,  extremely  favorable.  AVhen  the  cataract  is  the  result 
of  other  changes  in  the  eye,  or  is  associated  with  active  or 
past  diseased  conditions,  it  becomes  a  complicated  cataract. 
These  complications  may  consist  of  inflammatory  or  degen- 
erative changes  in  the  cornea  or  iris,  adhesion  of  the  iris  to 
the  lens,  a  tremulous  condition  of  the  iris,  a  lessened  condi- 
tion of  the  tension,  the  result  of  fluidity  of  the  vitreous  from 
extensive  choroidal  or  vitreous  disease,  or  the  tension  may  be 
increased,  as  glaucoma  is  not  infrequently  productive  of 
cataract.  When  the  cataract  is  complicated,  the  prognosis 
becomes  more  difiicult  in  proportion  to  the  extent  of  the 
accompanying  lesions. 

It  is  necessary  to  make  a  careful  examination  of  the  vision 
before  prognosticating  anything  as  regards  the  effect  of  the 
operation,  as  in  simple  cataract  the  patient  should  be  able  to 
recognize  a  lighted  candle  in  a  dark  room  at  twenty  feet  or 
more  with  ease,  and  also  be  able  to  indicate  its  position  when 
ten  feet  distant  and  held  in  various  positions  of  the  field.  If 
complications  exist,  the  quick  perception  of  the  light  will  be 
lost  and  portions  of  the  field  be  absent,  indicating  retinal 
detachment,  or  the  field  be  much  contracted,  the  result  of  glau- 
coma or  atrophy  of  the  optic  nerve.  If,  then,  the  vision  is 
thus  affected  or  the  light  perception  lost,  the  operation  for  the 
removal  of  the  cataract  is  not  to  be  undertaken,  as  no  chance 
of  improving  vision  remains.  In  addition  to  the  indications 
already  given  for  a  favorable  prognosis  in  cataract  extraction, 
we  should  have  the  cataract  ripe  and  a  pupil  which  responds 
promptly  to  the  instillation  of  atropine  and  the  patient  tract- 
able and  in  as  good  a  condition  as  possible  as  regards  the 
general  health.  The  amount  of  vision  attainable  is  dependent 
upon  the  skill  of  the  operator,  the  circumstances  surrounding 
both  patient  and  surgeon  at  the  time  of  the  operation,  and 
the  care  and  attention  given  the  case  after  the  extraction. 
A  certain  percentage  of  cases  are  necessarily  failures.  That  is, 
the  vision  is  only  quantitative  or  is  entirely  lost,  while  in  the 
best  results  the  patient  should  be  able  to  read  No.  C  at  ten 
yV     All   degrees  of    vision    attainable 


HARD  CATARACT— TREATMENT.  327 

between  these  two  results  are  termed  partial  successes.  The 
probable  chances  of  a  good  result  can  only  be  stated  by  the 
surgeon  after  a  full  examination  of  ithe  cataract  and  the  condi- 
tion  of  the  patient. 

Treatment. — When  degenerative  changes  have  occurred  in 
the  lens  fibres  no  medical  treatment  will  cause  a  return  of 
their  transparency  and  nothing  remains  to  be  done,  beyond 
placing  the  eye  and  the  patient  in  such  a  condition  as  will 
render  the  necessary  surgical  measures  likely  to  give  the 
patient  vision.  That  lenticular  opacity  may  occur  and  disap- 
pear spontaneously,  or  as  the  result  of  medical  treatment, 
cannot  be  denied  without  impeaching  the  integrity  and  skill  of 
otherwise  undoubted  authorities  of  both  schools  of  medicine. 
There  is  no  question  but  that  in  the  incipient  stage  of  cataract 
a  great  deal  can  be  accomplished  in  retarding  the  progress  of 
the  opacity  for  an  indefinite  period  of  time,  or  even  clear  it  up 
to  such  an  extent  as  to  make  the  vision  entirely  normal.  The 
therapeutic  means  to  be  applied  must  be  carefully  individual- 
ized in  each  case,  and  in  the  selection  of  the  homoeopathic 
remedy  we  must  be  guided,  not  only  by  the  condition  of  the 
lens  or  the  eye,  but  also  by  the  general  symptoms  presented 
by  the  patient,  inasmuch  as  the  malnutrition  of  the  eye  is 
frequently  only  symptomatic  of  a  general  dyscrasia.  In  the 
absence  of  any  brilliant  results  from  the  medical  treatment  of 
cataract,  and  from  the  fact  that  retrograde  changes  can  only 
be  accomplished  by  continued  medication  for  months,  too  little 
attention  has  been  given  the  matter  by  those  in  our  own  school, 
who,  if  they  would  abandon  the  old  notion  of  the  utter  impos- 
sibility of  curing  cataract  by  therapeutic  means,  and  give 
their  cases  the  close  study  necessary,  would  find  that  we  had 
not  yet  reached  the  limits  of  the  application  of  the  law  of 
similars.  That  there  may  be  no  doubt  as  to  the  results 
accomplished  by  the  medication  in  cataract,  the  condition  of 
the  lens  and  the  vision  should  be  tested  and  recorded,  and 
when  the  cataract  is  of  slow  progress,  the  vision  should  again 
be  tested,  after  an  interval  of  two  or  more  weeks;  if  during 
this  time  there  has  been  no  chancre  in  the  habits  of  the  indi- 


328  DISEASES  AND  INJURIES  OF  THE  EYE. 

vidual  and  the  vision  is  the  same  or  has  lessened,  we  are 
prepared  to  attempt  the  medical  treatment  of  the  cataract 
If  now,  from  time  to  time,  we  find  an  improvement  in  the 
■\dsion  with  or  without  change  in  the  appearance  of  the 
cataract,  we  must  acknowledge  that  the  probabilities  are  that 
the  result  has  been  obtained  by  the  use  of  the  remedies. 
If,  during  the  time  the  vision  diminishes  and  the  opacity 
increases,  wo  are  ready  to  accord  it  a  failure,  then  why  not 
claim  for  the  better  result  that  it  followed  from  the  exhibition 
of  the  remedy? 

Many  cases  of  cataract  which  appear,  are  so  far  advanced, 
or  the  condition  so  complicated  by  other  diseases,  as  to  render 
any  medical  treatment  useless  for  the  purpose  of  improving 
vision;  but  the  proper  treatment  of  these  cases  will  enable  us 
during  the  period  that  must  elapse  before  surgical  measures 
can  be  adopted,  to  put  both  the  eye  and  patient  in  a  better 
condition,  and  thus  achieve  greater  results  from  the  operation, 
than  would  be  possible  otherwise.  The  remedies  which  have 
been  employed  with  very  favorable  results  in  some  casesj  are 
Causticum,  Sepia,  Graph.,  Phos.,  Sulph.,  and  Conium.  Many 
others,  as  Chelid.,  Calc.  carb.,  Lycop.,  Magnes.  carb.,  Puis., 
Baryta  carb.,  and  Secale  cor.  have  been  reported  as  having 
removed  lenticular  cataract.  Galvanism  is  of  undoubted 
benefit  in  improving  the  nutrition  of  the  eye.  When  the  l^ns 
has  become  completely  opaque  and  the  cataract  mature,  the 
lens  must  be  extracted  before  the  vision  can  be  improved. 

Various  methods  for  the  removal  of- cataract  are  in  vogue 
and  these  operations  differ  according  to  the  condition  of  the  eye 
and  the  nature  of  the  cataract.  As  all  cataracts  are  not  favor- 
able for  operations  we  must  consider,  before  deciding  upon  the 
operation,  the  condition  of  the  eye  and  also  that  of  the  patient. 
As  regards  the  lens,  the  cataract  which  has  just  reached  matu- 
rity is  the  most  favorable  for  operation.  If  the  cataract  is 
immature,  the  cortex  is  not  sufficiently  hard  or  adherent  to  the 
nucleus,  and  there  is  great  danger  of  the  separation  of  the 
cortex  from  the  nucleus  and  of  the  cortical  substance  remain- 
ing in  the  anterior  chamber  where  it  may  excite  serious  inflam- 


OPERATIONS  FOR  SENILE  CATARACT.  329 

mation  of  the  iris,  or  tend  to  the  destruction  of  the  eye.  If 
the  cataract  is  over-ripe  there  will  bo  difficulty  in  removing  the 
semi-fluid  substance  with  the  nucleus,  unless  the  lens  is 
removed  together  with  its  capsule,  and  as  these  cases  are 
frequently  the  result  of  inflammatory  changes  in  the  eye,  they 
are  often  associated  with  degenerative  changes  which  will 
Tender  the  result  of  the  operation  unfavorable. 

The  eyeball  tension  should  be  normal,  the  pupil  properly 
responsive  to  light,  the  anterior  chamber  of  normal  depth  and 
the  iris  present  a  good  appearance.  If  the  iris  is  sluggish,  or 
adherent  to  the  lens  capsule,  dilated,  or  tremulous,  the  condi- 
tions are  much  less  favorable.  If  the  tension  is  increased,  the 
fleld  of  vision  contracted,  or  light  perception  deficient,  the 
surgical  operation  can  only  be  attempted  when,  in  the  judg- 
ment of  the  surgeon,  a  bare  chance  exists,  and  when  the  patient 
is  advised  of  the  great  probability  of  failure.  The  general 
condition  of  the  patient  must  be  improved  as  far  as  possible  by 
proper  nourishment  and  exercise,  to  prepare  him  for  the 
confinement  necessarily  attendant  upon  the  operation.  If  the 
patient  is  suffering  from  some  cachexia,  with  great  depression 
of  vitality,  the  operation  is  contra-indicated. 

If  any  conjunctival  or  lachrymal  trouble  exists,  it  must  be 
cured  before  the  operation  can  be  undertaken.  Whether  one 
eye  should  be  operated  upon  while  the  other  is  yet  unaffected 
or  fair  vision  retained,  will  depend  upon  the  circumstances  of 
individual  cases.  As  a  rule  in  senile  cataract  it  is  better  not 
to  do  so,  unless  a  favorable  result  is  almost  certain.  When 
both  eyes  are  blind,  it  is  better  to  operate  upon  one  first,  and 
not  upon  the  other  for  at  least  two  months  afterwards.  For  if 
one  alone  is  operated  upon  and  the  result  is  not  satisfactory, 
the  modification  or  change  in  the  method  of  extraction  may 
enable  us  to  attain  a  good  success  in  the  second  eye,  which 
might  have  participated  in  the  failure  of  the  first  had  the  oper- 
ation been  performed  upon  both  at  the  same  time. 

OPERATIONS  FOR  SENILE  CATARACT. 

Of  the  variety  of  operations  performed  for  cataract  extrac- 
tion those  which  require  consideration  here  are  the  old  flap 


830  DISEASES  AND  INJURIES  OF  THE  EYE. 

operation,  the  modified  linear  of  Von  Graefe,  and  those  of  Le 
Brun  and  Liebrich.     The  relation  of  the  different  incisions  to 

the  cornea  will  be  understood 
^  by  reference  to  Fig.  126  which 
shows  that  of  the  flap  operation, 
FIG.  126.  FIG.  127.         FIG.  128.  Fig.  127  that  of  Von   Graefe, 

and  Fig.  128  that  of  Le  Brun  above  and  Liebrich's  below. 

The  Flap  Operation  deserves  but  a  passing  notice  as  it  has 
become  obsolete.  The  extraction  of  the  cataract  was  made 
through  a  large  wound  in  the  cornea,  made  by  a  Beer's  knife, 
without  interference  with  the  pupil  beyond  that  which  was 
occasioned  from  the  stretching  of  the  iris  during  the  passage 
of  the  lens  over  it.  Tho  results  when  the  operation  was 
successful  were  brilliant,  but  the  danger  of  suppuration  from 
so  large  a  wound  in  the  cornea  has  resulted  in  the  abandon- 
ment of  it  for  safer  methods. 

The  Reclinaiion  of  Cataract  has  passed  to  deserved  oblivion, 
from  the  fact  that  the  displacement  of  the  lens  into  the  vitre- 
ous, where  it  acts  as  a  foreign  body,  sooner  or  later  destroys 
the  eye,  or  causes  sympathetic  disturbance  of  the  other.  The 
operation  consists  in  the  introduction  of  a  cataract  needle 
about  a  line  and  a  half  from  the  cornea  in  the  outer  and  lower 
portion  of  the  sclera ;  the  needle  is  then  pushed  upward  and 
forward  until  it  rests  upon  the  upper  part  of  the  lens  which  is 
then  dislocated  and  pressed  slightly  downward  until  it  rests  in 
the  vitreous.  The  immediate  effect  of  the  operation  is  brill- 
iant, but  the  after  dangers  are  too  great  to  allow  of  its  perfor- 
mance except  in  very  rare  cases.  I  have  never  made  the 
operation  but  once,  and  then  in  a  patient  who  had  but  a  few 
months  to  live,  and  to  whom  it  gave  the  pleasure  of  vision 
while  life  lasted. 

MODIFIED  LINEAR  EXTRACTION. 

The  modified  linear  extraction  (Fig.  129)  was  first  practised 
by  Graefe  in  1865.  The  danger  of  suppuration  of  the  large 
corneal  wound  of  the  flap  operation  is  avoided  by  making  an 


MODIFIED  LINEAR  EXTRACTION. 


331 


incision  slightly  in  the  sclera  when  a  smaller  incision  will 
suffice  for  the  escape  of  the  lens.  The  bruising  of  the  iris  and 
its  subsequent  inflammation  is  largely  avoided  by  the  combi- 
nation of  an  iridectomy  with  the  operation.  The  modified 
linear  operation  as  now  made  by  most  operators  differs  in  some 
minor  particulars  from  that  originally  made  by  Graefe. 

The  incision  is  made  nearer  to  the  cornea  or  in  the  sclero- 
corneal  junction  and  increased  in  length.     The  danger  of  loss 


TIG.  129. 


of  vitreous  and  the  wounding  of  the  ciliary  processes  and 
subsequent  cyclitis  is  thus  lessened.  Improvements  have  also 
been  made  in  the  methods  of  opening  the  capsule. 

The  operation  is  divided  into  four  stages:  first,  the  corneal 
incision;  second,  the  iridectomy;  third,  the  laceration  of  the 
capsule ;  and  fourth,  the  delivery  of  the  lens. 

The  patient  should  be  put  in  as  good  a  condition  as  possible 
prior  to  the  operation  and  a  good  night's  rest  secured.  The 
rectum  should  be  emptied  a  few  hours  before  the  operation. 

An  anaesthetic  can  be  used  or  not  according  to  the  judg- 
ment of  the  operator  and  the  ability  of  the  patient  to  sustain 
the  pain.  In  the  majority  of  cases,  it  will  be  found  advisable 
to  use  it,  as  the  eye  can  then  be  perfectly  controlled  and  all 
muscular  contraction  is  avoided,  while  the  shock  of  the  opera- 
tion and  the  attendant  nervous  excitement  is  much  lessened. 


332  DISEASES  AND  INJURIES  OF  THE  EYE. 

Its  use  is  only  contra-indicated  by  the  struggling  and  its 
attendant  congestion  of  the  head,  and  the  probability  of  vom- 
iting either  during  or  after  the  operation.  Yet  I  am  inclined 
to  think  that  ill  results  from  such  causes  are  rather  rare,  if  the 
extraction  has  been  properly  performed  and  the  eye  well  band- 
aged afterward. 

The  iridectomy  which  forms  the  second  stage  of  the  opera- 
tion may  be  made  at  the  time  of  the  extraction,  or  some  weeks 
previous,  when  it  is  termed  a  preliminary  iridectomy;  that  it 
Las  its  advantages  is  now  conceded  by  all  operators.  As  a 
rule,  it  is  not  necessary  to  give  an  anaesthetic  for  the  perform- 
ance of  the  iridectomy,  but  from  the  behavior  of  your  patient 
during  this  operation,  you  are  able  to  determine  the  necessity 
of  anaesthesia  during  the  extraction.  Again,  there  are  further 
points  to  be  gained  by  making  a  preliminary  iridectomy.  You 
■are  able  to  judge  of  the  condition  of  the  cornea  and  thus 
decide  upon  the  proper  incision  for  the  individual  case,  of  the 
irritability  of  the  eye  from  operations,  the  ability  of  the 
patient  to  bear  the  confinement  necessary  after  an  operation, 
and  finally  of  his  tendency  to  that  low  grade  of  conjunctivitis 
which  frequently  retards  recovery  in  this  class  of  patients.  If, 
on  the  other  hand,  the  iridectomy  is  made  at  the  time  of  the 
extraction,  we  have  the  large  fresh  wound  of  the  iris  corres- 
ponding to  the  line  of  the  incision  in  the  cornea,  and  in  this 
the  amount  of  injury  to  the  eyeball  is  much  increased,  and  the 
dangers  from  traumatism  correspondingly  greater.  Moreover, 
the  hemorrhage  from  the  cut  iris  is  oftentimes  very  annoying, 
and  not  infrequently  complicates  the  operation  by  obscuring 
the  lens  to  such  an  extent  as  to  severely  impede  the  operation. 
Again,  during  the  process  of  removing  the  lens,  the  cut  edges 
of  the  iris  are  more  liable  to  be  bruised,  and  we  are  apt  to 
have  a  local,  if  not  general,  inflammation  of  the  iris,  which 
will  cause  adhesion  to  the  lens  capsule,  or  inflammation  and 
-consequent  opacity  of  the  capsule  itself. 

These,  then,  are  some  of  the  advantages  to  be  gained  by 
separating  the  two  operations.  The  objection  against  this 
method  of  procedure  is  the  fact  that  patients  coming  from  a 


MODIFIED  LINEAR  EXTRACTION.  33^ 

distance  must  either  remain  during  the  interim  separating  the- 
operations,  or  return  again  for  the  second  one.  This  is  quite 
an  obstacle  to  some  patients,  and  where  it  cannot  be  overcoma 
by  the  statement  that  the  prospects  of  vision  are  much  better 
from  the  division  of  the  operation,  it  will  be  necessary  to 
combine  them. 

The  iridectomy  should  be  made  upward,  in  the  usual  manner, 
with  an  angular  keratome  and  about  one-sixth  of  the  iris 
removed.  After  the  operation  a  bandage  is  applied,  and  the 
patient  confined  to  bed.  A  few  hours  afterward,  or  the  next 
morning,  when  the  bandage  is  reapplied,  atropine  is  to  be- 
instilled  to  prevent  adhesions  of  the  iris.  There  is  usually  no. 
reaction,  and  in  three  or  four  days  the  patient  is  allowed  to  go- 
about  as  before. 

When  the  extraction  is  made  by  the  modified  linear  method 
the  following  instruments  are  necessary:  a  speculum  for  hold- 
ing the  lids  widely  apart,  a  pair  of  fixation  forceps  to  steady 
the  eyeball,  a  linear  cataract  knife,  narrow  and  sharp,  a  pair  of 
iris  forceps  and  scissors,  a  cystotome  and  a  lens  scoop  of  hard 
rubber. 

The  patient  is  placed  in  a  recumbent  position  before  a  good 
light,  ether  administered  and  full  anaesthesia  produced  before 
any  attempt  is  made  to  proceed.     The  operator,  if  he  uses  the 


FIG.  130. 


right  hand,  stands  behind  the  head  of  the  patient  for  the  right 
eye,  and  at  the  left  side  for  the  left.  The  lids  are  then  sepa- 
rated by  the  speculum,  or  the  upper  lid  raised  by  an  elevator 
or  the  finger  of  an  assistant.  The  first  stage  of  the  operation 
is  now  begun.  AVith  the  fixation  forceps  (Fig.  130),  the 
operator  seizes  the  conjunctiva  below  the  cornea  and  makes 
his  incision  with  the  linear  knife  (Fig.  131),  the  point  of 
which  must  be  entered  on  the  temporal  side,  exactly  in  the 
sclero-comeal  junction  and  directed  towards  the  centre  of  the 


334  DISEASES  AND  INJURIES  OF  THE  EYE. 

pupil;  having  arriyed  there,  the  point  must  be  raised  and 
carried  across  the  anterior  chamber,  close  in  front  of  the  iris, 
and  made  to  emerge  through  the  corneo-scleral  ring  at  a  point 
on  a  level  with  that  of  the  entrance;  with  a  slight  sawing 
motion,  the  blade  should  now  be  made  to  cut  its  way  out, 
keeping  precisely  in  the  corneo-scleral  junction  to  the  last, 


when  the  edge  should  be  turned  to  the  front  to  cut  through 
the  conjunctiva,  of  which  a  short  flap  should  be  left  attached 
to  the  cornea.  At  this  stage,  the  cornea  may  collapse  or  blood 
may  fill  the  anterior  chamber.  In  the  latter  case,  the  lid  must 
be  dropped  for  a  few  moments  and  cold  water  applied;  when 
the  hemorrhage  has  ceased,  the  blood  may  be  pressed  out  of 


the  eye  by  gently  wiping  the  wound  with  a  bit  of  soft  muslin, 
while  the  upper  edge  of  the  incision  is  slightly  pressed  back- 
ward by  the  hard  rubber  spoon  (Fig.  132). 

The  second  stage  in  the  operation  is  the  iridectomy ;  this  is 
intended  to  enable  the  lens  to  escape  more  easily,  and  also  to 
prevent  the  prolapse  of  the  iris  in  the  wound,  which  would 
tend  to  prevent  healing,  or  become  a  source  of  irritation  to 


FIG.  133. 

the  eye.  It  is  not  necessary  to  remove  a  large  portion  of  the 
membrane.  The  fixation  forceps  are  now  held  by  the  assistant 
while  the  operator  turns  back  the  conjunctival  flap  with  the 
closed  iris  forceps  (Fig.  133),  and  if  the  iris  presents  itself 
at  the  centre  of  the  wound,  it  is  seized  by  the  forceps,  or  if 
not,  the  forceps  are  introduced  into  the  anterior  chamber  and 
the  membrane  caught  near  its  pupillary  margin,  drawn  out. 


MODIFIED  LINEAR  EXTRACTION.  835 

and  a  piece  about  5  mm.  wide  excised  close  to  the  sclerotic, 
with  the  iris  scissors  (Fig.  134). 

The  ihird  stage  of  the  operation  is  the  incision  of  the 
capsule;  this  is  done  by  introducing  either  a  Graefe  (Fig. 
135),  or  Knapp's  cystotome  into  the  anterior  chamber,  just 
behind  the  border  of  the  iris,  at  the  lower  edge  of  the  pupil, 


and  making  a  clean  curved  incision  in  the  capsule  parallel  to 
the  incision  in  the  cornea.  Various  other  methods  of  incising 
the  capsule  have  been  proposed,  either  by  numerous  cuts,  or 
by  a  circular  incision,  which  would  remove  the  central  portion 
of  the  capsule.  The  cystotome  is  made  with  a  malleable 
shank  so  that  it  can  be  bent  to  suit  the  brow  of  either  eye. 

The  fourth  stage :  The  edge  of  the  lens  may  now  be  made  to 
present  its  edge  externally  by  pressing  gently  with  the  spoon 
at  the  lower  margin  of  the  cornea ;  as  the  lens  advances  into 


FIG.  136. 


the  wound  the  spoon  follows  it  up  over  the  surface  of  the 
cornea  and  receives  it  as  it  escapes  from  the  eye.  If  any 
cortex  remains,  it  may  generally  be  brought  into  the  pupil  by 
a  gentle,  circular,  rubbing  motion  of  the  lids,  and  may  be 
pushed  out  of  the  anterior  chamber  by  pressure  upon  the  lower 
lid,  while  the  upper  lid  is  slightly  raised  and  with  slight  pres- 
sure depresses  the  upper  lip  of  the  wound.  If  the  lens  does 
not  readily  present  itself  in  the  wound  the  capsule  should  be 
again  incised,  or  if  the  lens  presents,  but  does  not  readily 
escape,  the  corneo-scleral  wound  should  be  again  enlarged 
with  the  scissors. 


336  DISEASES  AND  INJURIES  OF  THE  EYE. 

It  is  at  this  period  of  the  operation  that  there  is  the  greatest 
danger  of  the  escape  of  the  vitreous;  if  it  is  small  in  amount, 
it  is  of  no  particular  consequence,  but  a  great  loss  may  be 
followed  by  hemorrhage  of  the  choroid  or  final  shrinking  of 
the  ball.  If  tlie  prolapse  of  the  vitreous  occurs  before  the 
escape  of  the  lens,  the  latter  should  be  removed  by  means  of  a 
wire  loop  (Fig.  136) ;  afterwards  a  pressure  bandage  should  be 
applied  as  quickly  as  possible. 

It  happens  in  the  majority  of  cases  that,  after  the  nucleus 
has  escaped,  a  portion  of  the  softened  cortex  remains.  This 
should  be  removed  by  a  gentle  rotary  motion  of  the  finger 
upon  the  closed  eyelid,  or  by  pushing  the  lower  lid  upwards 
towards  the  wound.     If  this  is  not  sufficient,  gentle  pressure 


may  be  made  upon  the  lower  portion  of  the  cornea  by  the  hard 
rubber  scoop,  when  the  remaining  portions  will  pass  out. 
The  wound  is  to  be  thoroughly  cleared  by  the  forceps  of  any 
prolapse  of  the  iris,  lens  substance,  or  clot,  and  it  should  be 
observed  whether  there  is  an  accurate  approximation  of  the 
lips  of  the  wound.  The  conjunctival  sac  should  be  cleansed 
with  a  weak  boracic  acid  solution,  and  a  compress  bandage 
applied  to  both  eyes. 

The  after  ireaiment  consists  in  the  confinement  of  the  patient 
to  bed,  in  a  dark  room,  and  the  dressings  made  by  candle  light. 
The  patient  should  take  that  position  in  bed,  upon  the  back  or 
side,  which  may  be  most  comfortable  to  him,  and  which  can  be 
maintained  for  at  least  ten  hours  without  change.  Na 
muscular  effort  whatever  is  to  be  made,  and  the  food  must  be 
liquid  so  as  to  avoid  chewing  motions,  but  should  be  nutri- 
tious, as  the  strength  of  the  patient  needs  sustaining.  If  all 
has  gone  well,  there  is  no  pain  beyond  a  little  smarting,  or  an 
occasional  twinge  from  the  accumulation  of  tears  between  the 
eyelids,  which  is  relieved  as  the  tears  are  felt  to  pass  down  the 
cheek.  If  possible,  sleep  should  be  obtained  during  the  first 
night  following  the  operation,  as  absolute  quiet  is  of  much 


LINEAR  EXTRACTION— CAPSULAR  CATARACT.  337 

greater  value  at  this  stage  of  the  treatment  than  at  any  time 
later.  The  bandage  may  be  reapplied  eight  or  ten  hours  after 
the  operation,  if  the  eye  is  uncomfortable,  but  the  eye  should 
not  be  opened.  If  there  is  no  discomfort,  the  bandage  need 
not  be  disturbed  for  twenty-four  hours.  The  nature  of  the 
discharge  upon  a  bit  of  muslin  covering  the  eye  and  the  condi- 
tion of  the  lids  will  indicate  the  progress  of  the  case.  If  there 
has  been  no  pain  and  the  secretion  is  of  mucus  and  scanty, 
the  indications  are  good.  If  there  is  pain,  iritis  is  to  be  feared 
and  atropine  should  be  thoroughly  used.  If  the  lid  becomes 
puffy  and  the  discharge  increases,  the  danger  of  suppuration 
of  the  wound  is  imminent,  and  it  may  be  necessary  to  use  hot 
fomentations  of  calendula  lotion  and  stimulate  the  patient. 

If  no  complications  arise  after  the  second  day,  a  drop  of 
atropine  solution  is  to  be  put  into  the  eye  night  and  morning 
when  the  dressings  are  changed.  After  a  week 
or  ten  days,  the  patient  may  be  allowed  to  sit  up, 
'  /  and  after  this,  the  light  should  be  gradually 
admitted  to  the  room  and  the  patient  provided 
with  a  shade;  usually,  two  or  three  weeks  are 
required  for  the  after  treatment.  In  about  a 
month  or  six  weeks,  if  all  irritation  has  disap- 
peared from  the  eye,  glasses  may  be  worn. 

The  operations  of  Liehrich  and  Le  Brim  have 
recently  come  into  vogue.  In  both,  the  section 
lies  in  the  cornea  and  the  operation  is  performed  with  a 
somewhat  broader  linear  knife  and  without  an  iridectomy. 
In  Le  Brun's,  the  incision  is  made  in  the  upper  portion  of 
the  cornea  bv  entering  the  knife  2  mm.  in  the  sclera  and 
bringing  it  out  at  a  point  opposite  and  cutting  directly  out- 
ward, so  that  the  incision  ends  in  the  cornea  slightly  above 
the  pupil. 

The  directions  of  the  different  incisions  are  given  in  Fig. 
137,  G  showing  the  place  where  the  Graefe  original  incision 
is  made,  S  where  it  is  now  generally  made,  D  the  place  of 
section  of  Liebrich  when  it  is  made  in  the  upper  section,  L  in 
the  upper  portion  is  the  section  of  Le  Brun,  and  L  that  of 

22 


338  DISEASES  AND  INJURIES  OF  THE  EYE. 

Liebrich,  when  the  incision  is  made  in  the  lower  section  of  the 
cornea. 

The  modified  Liebrich  operaiion  forms  an  easier  method  of 
extraction  than  that  of  the  modified  linear  and  the  results  are 
oftentimes  better.  A  preliminary  iridectomy  should  be  made 
and  the  incision  laid  in  the  upper  portion  of  the  cornea;  the 
point  of  a  linear  cataract  knife  broader  than  the  Graefe  is 
entered  in  the  sclera  about  1  mm.  from  its  border  at  the  upper 
third  and  carried  directly  across  the  anterior  chamber  and 
brought  out  at  a  corresponding  point  opposite.  The  incision 
is  completed  by  passing  with  a  slight  curve  through  the  cornea, 
so  that  the  centre  of  the  incision  lies  on  the  cornea  midway 
between  the-edge  of  the  pupil  and  'the  periphery  of  the  iris. 
The  balance  of  the  operation  and  the  after  treatment  are  the 
same  as  that  described  for  the  modified  linear. 

Operations  for  ihe  removal  of  ihe  lens  in  its  capsule  have 
been  devised  and  perfected  by  Paganstecher  and  others,  and 
are  suitable  in  some  cases,  as  in  the  Morgagnian  cataract.  But 
these  operations  necessitate  the  introduction  of  a  scoop  or 
other  instruments  into  the  eye  and  are  apt  to  be  attended  by 
extensive  loss  of  vitreous  or  traction  upon  the  ciliary  body  to 
the  imminent  danger  of  the  eye. 

CAPSULAR   CATARACT. 

Opacities  of  the  lens  capsule  are  rare,  and  result  from  the 
deposits  of  neoplastic  masses  upon  its  anterior  surface,  during 
an  iritis,  keratitis,  or  perforation  of  the  cornea,  forming 
anterior  polar  or  pyramidal  cataracts.     When  occurring  upon 

the    posterior 
portion    of   the 
capsule  they  are 
Fi^-138.  called  posterior 

j)olar  cataracts  and  are  seldom  visible  without  careful  focal 
illumination  when  they  present  either  a  patchy  or  stellate 
appearance  as  in  Fig.  138  and  arise  from  inflammatory  aflfec- 
tions  of  the  deeper  structures  of  the  eye. 


APHAKIA— LUXATIO  LENTIS.  '  839 

These  capsular  opacities  are  rarely  amenable  to  treatment, 
but  may  be  stationary  and  interfere  but  slightly  with  vision  if 
not  extensive  or  central. 

Secondary  or  Membraneous  Cataract  is  a  variety  of 
capsular  cataract  which  may  follow  cataract  extraction.  Opaci- 
ties form  in  the  pupil  some  time,  often  months,  after  the 
removal  of  the  lens.  It  may  be  filmy,  like  a  delicate  cobweb, 
which  can  only  be  detected  by  oblique  illumination,  or  appear 
as  a  white  membrane  in  the  pupil.  It  is  due  to  the  proliferation 
of  the  cells  of  the  capsular  tissue,  or  results  from  iritic  inflam- 
mation, and  the  iris  is  often  adherent  to  it. 

The  methods  generally  preferred  are  to  tear  an  opening  in 
the  centre  of  the  opacity  by  means  of  two  needles  introduced 
in  the  same  manner  as  described  for  discission.  The  utmost 
gentleness  must  be  exercised  as  the  slightest  traction  upon  the 
tough  membrane  is  often  sufficient  to  cause  a  cyclitis  which 
may  leave  the  eye  in  a  worse  condition  than  before.  If  the 
membrane  is  very  tough  the  operation  of  iridotomy  (see 
page  289)  is  often  more  practical. 

APHAKIA. 

Aphakia  or  the  absence  of  the  lens  may,  in  rare  cases,  be  a 
congenital  condition.  In  the  acquired  form,  it  is  the  result  of 
the  removal  of  the  lens,  as  after  cataract  operations.  It  requires 
a  strong  convex  glass  from  +  4r|  to  +  4  for  distant  vision, 
depending  upon  the  original  refractive  condition  of  the  eye. 
As  the  power  of  accommodation  is  also  lost  with  the  removal 
of  the  lens,  a  stronger  glass,  usually  +  3^  to  +  3,  will  be 
required  for  near  vision.  Astigmatism  is  often  present  in 
these  cases  and  its  correction  by  combined  sphero-cylindrical 
glasses  oftentimes  adds  much  to  the  vision  of  the  patient. 

LUXATIO  LENTIS. 

Dislocation  of  the  lens  may  be  congenital  or  result  from 
injury.  In  these  cases  the  iris  is  tremulous,  and  the  edge  of 
the  lens  may  be  seen  in  the  pupil  with  the  ophthalmoscope, 


340 


DISEASES  AND  INJURIES  OF  THE  EYE. 


appearing  as  a  dark  curved  line  on  the  red  background  of  the- 
fundus.  If  the  displacement  is  congenital,  the  lens  remains- 
clear  and  operative  interference  is  not  indicated.  The  vision 
may  sometimes  be  improved  by  the  use  of  a  proper  convex 
glass. 

If  the  lens  is  loose  and  acts  as  a  foreign  body,  it  should  be 
removed  at  once  and  inflammation  averted.  The  incision  is 
made  as  for  cataract  extraction  and  a  wire  or  fenestrated  scoop 
is  introduced  behind  the  lens  and  the  lens  removed  in  its  cap- 
sule. The  procedure  may  be  facilitated  by  introducing  a 
needle  through  the  cornea  and  passed  behind  the  lens  so  that 
the  lens  is  held  in  position,  while  the  scoop  is  introduced  and 
the  lens  removed  upon  the  scoop.  When  the  lens  is  dislocated 
beneath  the  conjunctiva,  it  should  not  be  disturbed  until  the 
sclero-corneal  rupture  is  healed,  when  it  is  easily  removed  by- 
an  incision  through  the  conjunctiva. 


CHAPTEK    XVIL 

DISEASES  OF  THE  VITREOUS. 

ANATOMY. 

The  vitreous  body  is  a  transparent,  gelatinous  mass  occupy- 
ing the  larger  portion  of  the  interior  of  the  eye,  about  four- 
fifths,  through  which  the  light  passes  to  reach  the  retina.  It 
forms  a  support  for  the  delicate  structures  of  the  retina,  from 
which  it  is  separable  except  about  the  optic  nerve  entrance. 
Its  anterior  portion  is  hollowed  for  the  lens  and  its  capsule  to 
Avhicli  it  is  adherent.  The  vitreous  is  inclosed  throughout, 
except  in  front,  by  a  thin  glassy  membrane,  the  hyaloidea. 
It  has  no  blood-vessels  in  its  structure  in  adult  life,  being 
dependent  upon  the  vascular  supply  of  the  retina  and  choroid 
for  its  nutrition.  Although  presenting  no  structural  elements 
in  the  fresh  condition,  when  hardened  it  appears  to  be  divided 
into  concentric  segments  by  minute  prolongations  of  the 
hyaloidea,  which  also  give  out  a  radial  striation  around  the 
optic  nerve  entrance.  At  the  posterior  surface  of  the  lens 
certain  cellular  elements,  which  appear  to  be  white  blood 
corpuscles  with  amoeboid  movements,  are  found;  other  cells 
of  stellate  shape  have  also  been  described  by  some  authorities. 
Between  the  optic  nerve  disc  and  the  posterior  surface  of  the 
Ions  is  also  a  minute  canal  w'hich  in  the  foetus  carries  the 
hyaloid  artery,  derived  from  the  central  artery  of  the  retina 
and  which  carries  forward  the  nourishment  to  the  lens  during 
its  development.     In  rare  cases  this  artery   persists  in  life. 


342  DISEASES  AND  INJURIES  OF  THE  EYE. 

The  hyaloid  membrane,  at  the  anterior  portion  of  the  vitreous 
becomes  firmer,  is  closely  attached  to  the  ciliary  body,  and  is 
known  as  the  zonule  of  Zinn,  which  presents  a  distinct  fibrous 
structure.  The  fluid  of  the  vitreous  body  consists  of  water 
containing  some  albuminate  of  soda  and  a  little  mucin. 

DISEASES  OF  THE  VITREOUS. 

Disease  of  the  vitreous  occurs  very  rarely  as  a  simple  aflfec- 
tion,  except  as  the  result  of  senile  degeneration,  as  it  presents 
little  evidence  of  organized  structure,  but  as  its  nutrient 
elements  are  derived  from  the  ciliary  body,  choroid  and  retina, 
it  often  participates  in  the  inflammatory  diseases  of  these 
tissues,  and  hence  may  also  be  the  seat  of  acute  or  chronic 
inflammation  which  affects  these  structures.  The  morbid 
changes  are  more  commonly  those  which  result  from  variations 
in  the  density  of  its  structure,  and  the  presence  of  opacities, 
fixed  or  floating  and  of  varying  size. 

HYALITIS. 

Inflammation  of  the  vitreous  is  characterized  by  the  migra- 
tion of  white  blood  corpuscles  and  their  proliferation  and 
these  changes  are  often  readily  observed  by  the  ophthalmo- 
scope, when  the  anterior  portions  of  the  vitreous  are  trans- 
parent. Hyalitis  may  be  serous,  plastic,  or  suppurative, 
according  to  the  nature  of  the  inflammatory  exudation  of  the 
neighboring  tissues  which  have  involved  the  vitreous. 

Causes. — In  addition  to  the  causes  already  enumerated, 
hyalitis  occurs  as  the  result  of  blows,  wounds  of  the  more' 
posterior  portions  of  the  globe,  and  the  penetration  and  lodg- 
ment of  foreign  bodies  in  the  eye. 

Symptoms. — Any  affection  of  the  vitreous  is  known  only  by 
its  effect  in  causing  it  to  become  turbid  and  fluid,  thus  impair- 
ing tiie  vision.  This  turbidity  results  from  the  infiltration 
and  proliferation  of  the  cell  elements  which  may  also  form 
opaque,  membranous  masses.     These  may  be  either  floating 


OPACITIES  OF  THE  VITREOUS.  343 

or  stationary,  and  if  sufl&ciently  large  are  readily  seen  with  the 
optlialmoscope  in  the  direct  method,  when  the  mirror  is  held  a 
few  inches  from  the  eye  and  the  patient  directed  to  turn  the 
eye  rapidly  in  various  directions,  which  gives  the  opacity 
motion  and  it  will  be  discovered  as  it  slowly  Hoats  past  the  area 
behind  the  pupil. 

Treatment. — The  treatment  should  be  directed  to  the  cause 
and  for  the  indications  of  remedies  useful,  reference  should 
be  made  to  those  given  for  the  inflammatory  diseases  of  the 
iris,  ciliary  body,  and  choroid. 

OPACITIES  OF  THE  VITREOUS. 

The  vitreous  body  is  not  absolutely  transparent,  for  in  most 
healthy  eyes  dark  bodies  may  be  seen  on  looking  through  a 
pin  hole  in  a  card,  in  a  bright  light,  or  at  a  white  wall  or 
cloud.  These  motes,  or  muscce  voUiantes  appear  in  various 
forms  floating  about  in  the  field  of  vision.  They  seem  to  the 
patient  to  consist  of  minute  bead-like  masses  which  are  strung 
together  in  various  shapes,  or  of  delicate  filaments  having  a 
webby  appearance,  and  seem  to  ascend  from  the  lower  part  of 
the  field  of  vision  and  then  fall  down  again,  or  when  the 
attempt  is  made  to  watch  them,  they  pass  out  of  sight  only  to 
return  when  some  near  object  is  regarded.  As  they  seem  to 
retain  the  same  relative  distance  from  the  visual  axis,  they  are 
often  annoying,  but  do  not  interfere  with  the  distinctness  of 
vision.  These  various  appearances  are  due  to  the  presence  of 
minute  cells  in  some  portions  of  the  vitreous,  which  intercept 
the  light  rays  and  cause  shadows  to  be  thrown  upon  the  retina. 
The  number  of  these  cells  is  often  greatly  increased  by  over- 
work of  the  eyes  at  near  objects,  from  derangement  of  the 
digestive  organs,  and  in  myopia.  In  the  latter  disease  they 
become  very  annoying,  from  the  fact  that  the  shadows  cast  by 
them  are  often  better  defined  than  external  objects.  When 
they  become  very  troublesome  in  nearsighted  persons,  they 
are  an  indication  of  the  progressive  condition  of  the  myopia. 
It  seems  to  be  the  result  of  immoderate  tea  drinking  in  many 


344 


DISEASES  AND  INJURIES  OF  THE  EYE. 


cases,  which  produces  digestive  derangement  and  thus  affects 
the  eye  secondarily.  Such  opacities  as  these  are  always  too 
minute  to  be  seen  with  the  ophthalmoscope. 

Treatment  —  When  occurring  in  myopia,  they  may  be 
greatly  dissipated  by  the  use  of  a  properly  adapted  concave 
glass  which  by  making  the  vision  more  distinct,  tends  to 
diminish  their  effect.  When  caused  by  too  close  work  of  the 
eyes,  rest  must  be  prescribed,  and  when  connected  with  diges- 
tive troubles  these  must  be  corrected.  There  are  none  of  our 
remedies  which  are  specially  indicated  for  this  condition,  but 
when  used  for  the  primary  disease  which  is  the  exciting  cause, 
they  are  frequently  dispelled.  When  immoderate  tea-drinking 
is  probably  the  cause,  abstinence  should  be  practiced,  or  the 
consumption  of  tea  much  lessened  and  more  food  taken. 

Opacities  of  the  Vitreous.  —  The  vitreous,  which  is  of 
firmer  consistency  in  its  outer  portion  than  in  the  more  central 
parts,  becomes  in  old  age  more  liquid,  from  the  fatty  degener- 
ation of  its  elements.  This  condition,  or  sijnchisis,  results 
also  from  inflammatory  affections  of  the  choroid  and  causes 
lessening  of  the  tension  of  the  eye,  while  the  vitreous  contains 
foating  opacities  which  are  observable  both  objectively  and 
subjectively.  In  some  cases  of  fluidity  of  the  vitreous,  called 
synchisis  scintillans,  numerous  floating  crystals  of  cholesterine 
are  present,  which,  in  an  ophthalmoscopic  examination,  reflect 
the  light  and  glitter  like  minute  specks  of  gold,  which  rapidly 
move  through  the  vitreous  on  motion  of  the  eyeball. 

Opacities  of  the  vitreous  may  vary  in  degree  from  a  diffuse 
cloudiness  to  a  dense  mass  which  obstructs  all  view  of.  the 
optic  disc  or  fundus. 

Causes. — This  condition  may  be  due  to  any  inflammatory 
condition,  particularly  syphilitic,  of  the  interior  structures, 
which  causes  an  hyper  -  secretion  of  serous  fluid  into  the 
vitreous  chamber.  As  the  primary  disease  subsides,  the 
vitreous  may  gradually  clear  and  become  transparent,  or 
opacities  of  greater  or  less  extent  remain.  When  these 
opacities  are  movable,  or  floating,  they  indicate  a  fluid  condi- 
tion of  the  vitreous. 


OPACITIES  OF  THE  VITREOUS.  345 

Symptoms.  —  These  opacities  may  interfere  very  seriously 
"with  the  vision,  if  they  lie  in  the  visual  axis,  or  may  occasion 
no  inconvenience  when  out  of  the  line  of  vision  and  may  be 
overlooked  by  the  observer  in  an  ordinary  ophthalmoscopic 
examination. 

Diagnosis. — With  the  ophthalmoscope,  in  the  direct  method, 
these  opacities,  if  not  too  minute  or  the  vitreous  turbid,  may 
be  readily  distinguished  by  using  a  proper  correcting  glass 
for  the  fundus  when  the  opacity  is  situated  near  the  retina, 
while  if  near  the  centre  of  the  eye  a  convex  8  will  be  required, 
and  when  more  anterior  even  a  convex  4  or  5  will  be  necessary. 
A  weak  illumination  should  be  used  and  the  patient  directed 
to  move  the  eye  rapidly  in  various  ways  so  as  to  give  direction 
to  the  floating  body,  which  soon  comes  in  view  behind  the 
pupih 

Tbeatment. — In  general  the  continuation  of  the  remedies 
which  have  been  used  for  the  productive  cause  of  the  opacities 
are  still  indicated;  such  remedies  as  Kali  iod.,  Kali  mur., 
Hepar,  Gels.,  Phos.,  and  Lachesis  will  prove  more  useful  than 
others  for  this  purpose.  In  cases  of  opacities  from  effusion  into 
the  vitreous,  the  patient  should  give  up  any  occupation  which 
tends  to  produce  congestion  of  the  eyes  or  head.  In  filmy 
opacities  of  the  vitreous  which  seem  to  involve  a  considerable 
extent  of  it,  improvement  of  vision  may  possibly  be  gained  by 
tearing  the  filaments  by  the  introduction  of  needles  through  the 
sclera  and  thus  separating  the  opacity  in  the  line  of  vision. 

Hemorehage  into  the  Yitreous  is  caused  by  rupture  of 
the  vessels  of  the  retina  or  choroid,  usually  the  latter,  and 
may  arise  spontaneously  during  inflammatory  diseases  of  its 
tissues  or  from  injuries  to  the  globe.  It  is  usually  accompa- 
nied by  localized  detachment  of  the  retina.  A  hemorrhagic 
opacity,  unless  very  small,  is  not  observable  -with  the  ophthal- 
moscope, as  it  more  frequently  fills  the  vitreous  and  prevents 
the  light  from  entering  the  interior,  and  nothing  but  a  dark 
reflex  is  obtainable;  with  oblique  illumination  a  dark  red 
appearance  behind  the  pupil  may  be  obtained.  Sometimes  the 
effused  blood  settles  down  as  a  coagulum  in  the  bottom  of  the 


346  DISEASES  AND  INJURIES  OF  THE  EYE. 

eye.  The  vision  is  naturally  greatly  impaired  and  the  patient 
complains  of  a  red  cloud  before  the  eyes;  this,  together  with 
the  sudden  onset  of  the  blindness,  which  may  occur  within 
half  an  hour,  will  render  the  diagnosis  easy.  As  already 
stated,  it  is  often  accompanied  by  detachment  of  the  retina, 
and  the  patient  must  be  examined  according  to  the  directions 
given  in  injuries  of  the  vitreous  in  the  chapter  on  Injuries  of 
the  Eye,  to  detect  it  and  determine  its  extent,  as  this  will 
affect  the  prognosis. 

The  blood  is  absorbed  more  readily  though  gradually  when  it 
comes  from  the  more  anterior  portions  of  the  choroid  or  ciliary 
body.  Weeks,  however,  are  required  to  cause  a  sufficient 
clearing  up  to  allow  of  a  partial  rctui'n  of  vision. 

After  hemorrhages,  black  threads  or  filaments  remain  either 
permanently,  or  for  a  long  time,  end  may  seriously  interfere 
with  vision,  or  when  a  coagulum  forms  tho  resulting  contrac- 
tion may  result  in  detachment  of  the  retina. 

Treatment. — When  due  to  injuries,  ico  compresses  and  rest 
in  bed  are  necessary  for  the  first  two  or  three  days  and  the 
administration  of  Arnica,  Bell.,  Hamamelis  and  Lachesis  will 
be  useful.  In  hemorrhage  arising  from  any  cause  it  is  better 
to  confine  the  patient  to  bed  for  ten  days  or  two  weeks  and 
bandage  the  eyes. 

Cysticeecus  is  a  parasite  which  may  also  be  found  in  other 
portions  of  the  eye.  While  more  common  in  Europe  it  occurs 
very  rarely  in  this  country ;  it  is  sometimes  observed  beneath 
the  retina,  or  in  the  vitreous,  and  requires  usually  the  enuclea- 
tion of  the  eye.  It  appears  as  a  bluish-white  cyst,  which 
increases  rapidly  in  size  and  induces  inflammatory  changes. 

Persistent  Hyaloid  Artery  is  a  rare  condition  which 
results  from  the  artery  which  is  destined  to  supply  nourish- 
ment to  the  lens  during  foetal  life  remaining  in  extra-uterine 
life.  It  appears  as  a.  dark  line  extending  from  the  posterior 
surface  of  the  lens  to  the  optic  disc.  Occasionally  other  blood 
vessels  appear  in  the  vitreous  from  the  development  of  mem- 
branous masses  or  as  prolongations  of  retinal  vessels,  and. 
may  disappear  or  become  permanent 


CHAPTEE    XVIII. 

DISEASES  OF  THE  CHOEOID 

ANATOMY. 

The  choroid  is  essentially  the  nutrient  membrane  for  the 
interior  structures  of  the  eyeball  and  consists  of  two  layers  of 
blood-vessels  held  in  position  by  a  stroma  of  connective  tissue. 
It  extends  from  the  optic  nerve  entrance,  around  which  it 
forms  a  ring,  nearly  to  the  sclero-corneal  junction,  where  it 
ends  in  a  series  of  folds  or  plaits,  the  ciliary  processes,  which, 
together  with  the  ciliary  muscle,  form  the  ciliary  body. 
Between  the  outer  surface  of  the  choroid  and  the  sclera,  a  lymph 
space  is  found  in  the  large-meshed  connective  tissue  which 
exists  between  these  two  membranes,  except  about  the  optic 
nerve  entrance  where  they  are  closely  united.  This  lymph 
space  is  held  to  be  in  direct  communication  with  that  of  the 
capsule  of  Tenon  and  the  other  lymph  spaces  of  the  eyeball, 
and  also  with  the  different  portions  of  the  choroid.  In  the 
choroid  four  layers  are  described  which  are  separated  by  endo- 
thelial cells  which  also  envelop  the  blood-vessels. 

Of  these  layers,  the  most  external  has  been  termed  the 
lamina  supra-choroidea,  a  membranous  layer  similar  to  the 
lamina  fusca  of  the  sclera,  to  which  it  is  united  by  connective 
tissue  meshes  holding  pigment  cells,  and  to  the  whole  choroid 
by  endothelial  cells,  thus  forming  a  lymph  space.  The  next 
layer,  the  tunica  vasculosa,  or  layer  of  large  blood-vessels,  pre- 
sents the  major  portion  of  the  stroma  of  the  choroid,  which 
consists  of  striated  fibre  cells  (6  Fig.  139)  and  pigment  cella 

347 


S48 


DISEASES  AND  INJURIES  OF  THE  EYE. 


(a  Fig.  139)  of  various  forms  uniting  the  elements  of  the 
choroid  together.  The  third  layer,  or  chorio-capillaris,  is  con- 
tinuous with  the  meshes  of  the  stroma 
with  finer  cells,  and  contains  the  capillary 
divisions  of  the  arteries  and  veins  of  the 
tunica  vasculosa.  The  remaining  layer 
is  the  lamina  vitrea  or  elastica,  a  struc- 
tureless, or  finely  fibrillated,  transparent 
membrane  covering  the  layer  of  capillary 
vessels  and  upon  which  rests  the  layer  of 
hexagonal  pigment  cells  of  the  retina. 
Through  the  stroma  of  the  choroid  and 
riG.  139.  along  its  vessels  are  found  smooth,  un- 

striated  muscular  fibres  which,   in   the  human   eye,   are  re- 
garded as  rudimentary. 

The  arteries  of  the  choroid  are  derived  from  the  anterior 
and  long  ciliary  arteries  which  send  recurrent  branches,  and 
from  the  short  ciliary  arteries  which  are  lost 
in  the  capillary  layer  after  numerous  sub- 
divisions. The  veins  beginning  as  capillaries 
in  the  chorio-capillaris,  take  in  the  tunica 
Tasculosa  a  whorl-like  form  and  uniting  into 
large  trunks,  constitute  the  vense  vorticos?e  (v 
Pig  140),  which  are  four  to  six  in  number, 
and  pass  obliquely  through  the  sclera  in  the  equatorial  region 
of  the  eye  to  empty  into  the  ophthalmic  vein;  a^ small  portion 
of  the  blood  from  the  anterior  portion  of  the  choroid  being 
returned  through  the  anterior  ciliary  veins. 

The  nerves  of  the  choroid  are  very  numerous  and  are 
derived  from  the  third,  fifth  and  sympathetic  through  the  long 
and  short  ciliary  nerves  and  form  in  the  choroid  fine  plexuses 
of  nerves  with  many  ganglionic  cells. 


FIG.  1-tO. 


DISEASES  OF  THE  CHOROID. 


The  choroid  being  the  most  vascular  part  of  the  eye,  except 
the  ciliary  body,  and  being  related  by  continuity  of  structui-e 


DISEASES  OF  THE  CHOROID.  849 

with  the  ciliary  body  and  through  it  with  the  iris,  as  we  have 
already  seen,  is  very  prone  to  participate  in  the  inflammatory 
action  of  those  more  anterior  structures  of  the  eye.  As  the 
outer  layers  of  the  retina  and  the  greater  portions  of  the 
vitreous  derive  their  nourishment  from  the  choroid,  we  find  it 
intimately  related  to  the  various  other  portions  of  the  globe, 
either  directly  or  indirectly,  and  hence  likely  to  be  implicated 
in  the  diseases  of  these  structures;  or,  diseases  of  the  choroid 
may  result  in  changes  in  the  retina,  vitreous,  lens  or  still  more 
remote  portions  of  the  eyeball. 

According  to  the  nature  of  the  exudation,  inflammation  of 
the  choroid  is  termed  serous,  plastic  or  purulent.  As  the 
choroid  is  a  delicate  tissue,  consisting  of  a  large  number  of 
blood-vessels  and  held  together  by  a  rather  loose  stroma, 
which  rapidly  becomes  saturated  with  the  products  of  inflam- 
mation when  these  are  thrown  out  in  large  quantity,  and  as 
the  sclera  from  its  density  offers  considerable  resistance  to 
infiltration  of  its  tissue,  the  copious  exudation  tends  towards 
the  interior  of  the  eye,  saturating  and  passing  through  the 
retina  to  the  vitreous,  from  which  it  may  pass  forward  and 
reach  the  aqueous.  As  the  pigment  layer  of  the  retina  lies 
upon  the  choroid,  diseases  of  the  latter  "cause  changes  in  the 
pigment  epithelium  which  may  result  in  its  absorption,  prolif- 
eration or  a  crowding  together  of  its  cells  in  masses. 

Causes. — Choroiditis  is  generally  due  to  inherited  or 
acquired  syphilis,  and  appears  usually  at  a  more  or  less 
remote  period  after  the  primary  and  secondary  stages  have 
passed.  It  also  results  from  injuries  to  the  eye,  occasionally 
arising  idiopathically  as  the  result  of  a  low  state  of  the  system 
or  as  a  sequel  of  severe  constitutional  diseases  and  after  severe 
mental  shock.  Highly  myopic  eyes  show  a  predisposition  to 
choroiditis  Vfhicli  may  follow  slight  provocation. 

Symptoms. — Inflammation  of  the  choroid,  unlike  diseases  of 
its  continuations,  the  iris  and  ciliary  body,  is  seldom  attended 
by  external  congestion,  pain,  heat  or  lachrymation.  The  vision 
may  be  either  seriously  or  only  slightly  impaired,  the  ^dsual 
defect  depending  upon  the  extent  and  nature  of  the  choroidal 


350  DISEASES  AND  INJURIES  OF  THE  EYE. 

affection,  r3  well  as  upon  the  location  of  the  lesion,  and  also 
upon  the  disturbances  of  the  vitreous. 

Diagnosis. — As  the  subjective  symptoms  are  not  pathogno- 
monic of  the  disease,  the  diagnosis  rests  almost  wholly  upon 
the  ophthalmoscopic  appearances.  If  the  anterior  portions  of 
ihe  eye  are  transparent  and  the  vitreous  clear,  we  shall  be  able 
"to  discover  any  changes  in  the  choroid  without  difficulty.  As 
the  pigment  layer  of  the  retina  commonly  participates  in  the 
choroidal  lesions,  it  is  often  very  difficult  to  determine  whether 
the  choroid  or  the  retina  has  been  the  seat  of  the  primaiy 
affection,  as  the  pigmentary  changes  are  as  frequently  the 
result  of  retinitis  or  hemorrhage,  as  of  choroidal  trouble. 
The  ophthalmoscopic  changes  usually  met  with  are  those  which 
indicate  atrophy  of  the  choroid.  These  may  be  partial  or 
complete,  and  occur  in  circumscribed  spots  of  varying  size. 
These  spots  are  paler  in  color  than  the  normal  choroid  or  may 
T3e  perfectly  white,  from  complete  atrophy  of  the  choroid  at 
the  point  of  lesion,  so  that  the  underlying  sclera  shines 
through.  These  patches  may  be  surrounded  by  aggregations 
of  the  pigment  epithelium  which  form  black  borders  of  vary- 
ing width  and  thickness,  or  the  pigment  itself  is  accumulated 
in  spots,  patches,  or  masses  in  the  retina  or  choroid,  without 
the  atrophic  appearances  of  the  choroid.  A  few  scattered  and 
small  spots  of  pigment  on  the  choroid,  or  in  the  retina,  often 
indicate  former  hemorrhages  when  there  are  no  evidences  of 
atrophy  of  the  choroid. 

HiPERiEMiA  OF  THE  CHOROID. — Acute  congestion  of  the 
choroid  occurs  frequently  in  connection  with  other  inflamma- 
tory diseases  of  the  eye.  Chronic  congestion  may  appear 
independently,  as  in  myopia,  or  from  prolonged  exposure  to 
bright  lights  and  great  heat,  as  in  men  who  are  employed  in 
rolling  mills.  It  is  almost  impossible  to  demonstrate  the 
condition  with  the  opthalmoscope  unless  it  exists  in  only  one 
eye,  or  from  the  variations  in  tint  of  the  fundus  which  may  be 
observed  to  occur  at  different  times  in  the  same  eye. 

Treatment. — When  the  condition  is  inferred,  the  eye  should 
"be  protected  by  dark  glasses  from  all  bright  lights  and  Bell., 
Phos.  or  Puis,  administered  internally. 


DISEASES  OF  THE  CHOROID.  .351 

Anemia  OF  the  Choroid. — In  conditions  of  extreme  anaemia 
the  choroid  becomes  of  a  pde  and  yellowish  hue,  but  requires 
no  special  treatment  beyond  that  indicated  for  the  general 
anaemic  condition. 

Choegiditis  Serosa  occurs  rarely  except  as  an  extension  of 
serous  inflammation  of  the  iris  or  ciliary  body,  the  most 
frequent  form  being  that  of  Irido-choroiditis  (Plate  IV,  Fig. 
4.)  A  thin,  serous  fluid  is  secreted,  usually  in  large  quantity, 
and  percolates  through  the  choroid  and  retina  into  the  vitreous, 
which  becomes  greater  in  quantity  and  clouded  and  the  tension 
of  the  eyeball  markedly  increased.  The  anterior  chamber 
appears  more  shallow  and  the  bus  and  iris  pushed  forward. 
If  the  tension  remains  plus  for  any  length  of  time,  the  retina 
and  optic  nerve  suffer  from  compression  and  the  vision  is 
destroyed.  When  the  process  is  acute,  it  is  accompanied  by 
photophobia,  severe  pain,  fever  and  rapid  diminution  of  the 
vision  with  marked  increase  of  the  tension,  and  has  been 
termed  acute  inflammatory  glaucoma,  or  glaucoma  fulmmanSy 
from  the  suddenness  of  the  attack. 

The  condition  is  usually  more  chronic  and  there  is,  often, 
little  pain,  slight  photophobia  and  only  temporary  increase  of 
tension  with  variable  vision.  At  times  the  vitreous  clears  up 
and  an  opthalmoscopic  examination  is  possible,  when  the 
retina  will  appear  hazy  or  grayish  and  the  retinal  vessels, 
particularly  the  veins,  appear  congested  and  tortuous. 

Causes. — The  disease  occurs  usually  as  a  complication  of 
serous  iritis,  or  in  eyes  that  show  extensive  posterior  synechia, 
or  occlusion  or  exclusion  of  the  pupil,  and  in  cases  where  the 
lens  has  been  injured  or  dislocated  into  the  vitreous.  The 
more  chronic  condition  occurs,  not  infrequently,  in  syphilitic 
patients  with  or  without  posterior  synechia. 

Treatment.— 1l\\q  cause  must  receive  due  consideration  and 
the  tension  be  carefully  watched.  Complete  rest  of  the  eyes 
must  be  enjoined  and  they  should  be  protected  from  the  light 
by  smoke-tinted  glasses,  or  in  acute  cases  the  eyes  should  be 
bandaged  and  the  patient  confined  to  bed.  If  there  is  much 
increase  of  tension,  eserino  solution,  locally,  may  be  of  much 


352  DISEASES  AND  INJURIES  OF  THE  EYE. 

benefit,  or  it  may  be  necessary  to  make  a  broad  iridectomy  to 
prevent  destruction  of  the  vision.  Much  may  be  expected 
from  our  remedies  in  this  affection  and  the  prompt  use  of 
Gelsemium,  Bryonia,  Phos.,  or  Jaborandi  will,  when  indi- 
cated, give  brilliant  results  and  prevent  the  necessity  of  opera- 
tive interference. 

Choroiditis  Plastica  is  characterized  by  the  exudation 
into  portions  of  the  choroid  of  a  plastic  material  consisting  of 
a  fibrinous  substance  with  numerous  round  cells.  These 
masses  of  exudation  appear  as  round  or  oval  masses  in  the 
stroma  of  the  choroid,  or  extend  into  the  retina.  It  may  be 
either  acute  or  chronic.  AYhen  acute  the  iris  is  usually 
affected,  and  there  is  pain,  ciliary  injection  and  diminution  of 
vision.  The  vitreous  is  at  first  cloudy,  but  as  it  becomes  clear 
the  ophthalmoscope  reveals  patches  of  whitish  exudation  of 
varying  size  which,  from  the  fact  that  the  retinal  vessels  are 
observed  to  pass  over  th^m,  are  seen  to  be  located  in  the 
choroid.  The  retina  may  be  implicated  and  the  vessel* 
partially  hidden  by  the  serous  infiltration,  and  the  optic- 
papilla  may  also  be  swollen.  In  other  cases  as  the  disease 
progresses  the  pigment  layer  is  disturbed  and  irregular  black 
patches  appear  in  the  spots,  or  surround  them  as  with  a  wall. 

In  the  majority  of  cases  the  condition  is  more  chronic  as  >l 
advice  is  sought  because  of  the  failing  vision,  and  the  diag- 
nosis depends  entirely  upon  the  ophthalmoscope.  On  exam- 
ination large  patches  of  the  choroid  will  be  found  to  be 
atrophied,  particularly  in  the  posterior  portion,  or  often  all 
stages  of  the  disease  will  be  seen,  from  the  primary  deposits  of 
exudation  or  of  pigment  in  some  portion  of  the  fundus,  while 
in  others  atrophic  spots,  with  thinning  of  the  retinal  pigment 
and  absorption  of  the  choroidal  stroma  will  appear,  or  the  whole 
choroid  will  present  an  atrophic  condition,  and,  if  the  retina, 
has  been  involved,  the  optic  disc  is  atrophied  and  the  retinal 
vessels  are  diminished  and  lessened  in  calibre  while  the 
fundus  exhibits  floating  opacities  which  mark  its  fluidity. 
For  clinical  purposes  two  varieties  are  described,  namely, 
choroiditis  disseminata  and  choroiditis  areolaris;  when  the 
retina  is  implicated,  the  disease  is  termed  chorio-retinitis. 


CHOROIDITIS  DISSEMINATA. 


ao3 


TLQ.  UL 


Choroiditis  Disseminata  (Fig.  141)  is  a  variety  of 
plastic  choroiditis.  In  this  variety,  all  of  the  patches  or  exa- 
dations  are  smaller  than  the  area  of  the  optic  disc  and  are 
scattered  through  the  otherwise  healthy  choroid,  although 
several  spots  may  coalesce  and  form  large  areas. 

All  stages  of  the  disease  are  frequently  present  in  the  eye 
at  the  same  time,  and  the  spots  appear  black,  red,  or  white 

according  as  the  pigment, 
choroidal  stroma,  or  sclera  are 
observed.  "When  the  patches 
are  white,  there  is  always  a 
border  of  pigment  surrounding 
them.  Both  eyes  are  apt  to  be 
attacked  but  not  to  the  same 
extent;  frequently  we  find  the 
disease  existing  only  in  one. 

Causes. — The  disease  may  be 
congenital  or  appear  in  young 
persons.  When  appearing  in 
adults,  it  is  often  indicative  of  syphilis  and  has  been  termed 
syphilHic  clioroidiiis.  The  choroidal  affection  generally  occurs 
from  one  to  three  years  after  the  primary  disease,  whether  it 
is  inherited  or  acquired.  It  is,  however,  not  necessarily  an 
indication  of  syphilis,  as  it  undoubtedly  arises  from  other 
causes,  as  those  mentioned  under  the  general  causes  of 
choroiditis. 

Sijmpioms. — The  principal  symptom  is  more  or  less  loss  of 
vision.  Pain  and  injection  of  the  eye  are  commonly  absent. 
If  only  one  eye  is  affected,  the  disease  may  be  far  advanced 
before  aid  is  sought,  but  if  the  other  eye  becomes  involved, 
the  loss  of  vision  is  such  as  to  cause  immediate  attention  to 
the  eyes. 

Disturbance  of  the  retinal  elements  by  the  exudation  in  the 
choroid  pressing  upon  or  crowding  the  layer  of  rods  and  cones 
causes  metamorphopsia,  micropsia,  or  megalopsia.  If  the 
choroidal  inflammation  affects  the  macula  lutea,  there  is  com- 
plete loss  of  central  vision,  while,  if  the  peripheral  portions 

23 


354 


DISEASES  AND  INJURIES  OF  THE  EYE. 


only  are  affected,  the  central  vision  may  be  but  slightly 
impaired.  Syphilitic  choroiditis  generally  gives  rise  at  an 
early  date  to  opacities  in  the  vitreous;  these  may  be  of  large 
size  and  readily  seen,  or  so  minute  and  numerous  as  to  cause  a 
general  diffused  haziness.  Sometimes,  in  syphilitic  cases,  the 
whole  fundus  will  be  studded  with  minute  dots  of  exudation  in 
the  choroid,  the  vision  be  much  affected,  the  vitreous  hazy, 
and  after  a  time  clear  up  and  leave  no  evidence  of  the  disease. 

Prognosis. — The  disease  is  very  apt  to  be  chronic  in  its 
course  and  may  continue  for  months.  In  all  cases  the  vision 
is  permanently  impaired,  and  the  acuteness  diminished  accord- 
ing to  the  extent  in  which  the  macula  lutea  and  the  more 
central  portions  of  the  choroid  are  involved.  Posterior  polar 
cataract  is  sometimes  developed  in  the  advanced  stage  and 
serious  opacities  of  the  vitreous  remain. 

Treatment. — It  is  well  to  prescribe,  in  addition  to  the 
internal  remedies,  rest  of  the  eyes  and  their  protection  from 
bright  lights  by  the  use  of  smoke-colored  glasses.  Confine- 
ment to  bed,  or  a  darkened  room,  is  rarely  necessary.  Stimu- 
lants and  the  use  of  tobacco  should  be  avoided  in  all  cases. 
When  the  disease  has  passed  into  the  stage  of  atrophy,  nothing 
can  be  done  beyond  the  prescription  of  slightly  tinted  glasses 
to  relieve  the  glare  arising  from  the  reflection  of  the  light 
from  the  sclera  when  the  spots  are  large.  The  remedies 
which  mil  be  indicated  are  Kali  iod.,  Merc,  cor.,  Aurum  mur.. 
Bell.,  Phos.,  Nux  vom.,  Kali  mur.,  and  Sulph. 

Choroiditis  Areolaris. — This  form  of  choroiditis  is  very 
similar  to  that  just  described  and  the  pathological  changes  are 
the  same,  but  in  addition  there  is  a  hypersemia  of  the  optic 
disc,  a  haziness  of  the  retina  around  the  disc  and  exudation 
along  the  retinal  vessels,  particularly  the  veins.  The  patches 
of  choroidal  change  are  large  or  small,  and  in  different  por- 
tions of  the  fundus,  as  in  the  disseminate  form.  There  is, 
however,  sudden  and  frequent  clouding  of  the  vitreous  and 
tendency  to  constant  relapses.  The  disease  is  syphilitic  and 
occurs  in  the  later  stages  of  the  constitutional  trouble. 

Treatment  is  the  same  as  that  for  disseminate  choroiditis. 


CHOROIDITIS  SUPPURATIVA— PANOPHTHALMITIS.  355 

Choroiditis  Suppurativa  —  Panophthalmitis. — Suppura- 
tive inflammation  of  the  choroid  is  the  most  severe  form  of 
choroiditis,  and  is  the  result  of  injuries  to  the  eye  which  cause 
suppurative  inflammation  of  the  iris  and  the  whole  uveal  tract  j 
as  it  generally  involves  the  entire  eye  and  even  its  appendages, 
the  term  panophthalmitis  well  describes  it. 

Symptoms, — The  lids  are  swollen  and  red,  the  entire  conjunc- 
tiva is  infiltrated  and  chemosed  and  there  may  be  a  purulent 
secretion  from  the  conjunctiva.  The  cornea  is  clouded  and  the 
iris  discolored  and  adherent,  and  a  yellow  reflection  appears 
behind  the  lens,  or  the  aqueous  is  so  clouded  that  the  deeper 
portions  of  the  eye  cannot  be  examined.  The  orbital  tissues 
become  infiltrated  and  the  eyeball  is  pressed  forward,  and  may 
be  immovable.  The  vision  is  rapidly  lost  and  even  perception 
of  light  may  be  absent.  There  is  generally  severe  pain  which 
lasts  during  the  whole  course  of  the  disease.  There  is  often 
febrile  disturbance  and  vomiting.  Again,  the  disease  may 
appear  with  much  milder  symptoms,  general  injection  of  the 
globe,  and  the  yellow  reflex  from  the  pus  behind  the  lens  being 
the  first  indications  of  this  grave  malady. 

Causes. — Among  the  traumatic  causes  which  may  be  men- 
tioned, are  injuries  of  the  iris,  wounds  or  foreign  bodies  lodged 
within  the  eyeball,  dislocation  of  the  lens  into  the  vitreous  by 
accident,  or  from  reclination  of  cataract,  or  after  operations 
for  the  extraction  of  cataract.  This  disease  may  also  result 
from  pyemia,  metastatic  abscess,  or  embolism  during  the 
puerperal  state,  low  fevers,  mumps,  caries  of  the  temporal  or 
cranial  bones,  or  cerebro-spinal  meningitis. 

Treatment. — If  the  case  is  a  mild  one,  atropine  and  hot  com- 
presses together  with  the  use  of  Phytolacca  or  Hepar  s.  may 
enable  us  to  save  the  eyeball  and  perhaps  some  vision;  when 
the  condition  has  been  excited  by  a  swollen,  cataractous  lens  or 
a  foreign  body,  it  should  be  removed,  if  possible.  If  the 
foreign  body  is  beyond  reach,  it  is  better  to  enucleate  the  globe 
unless  the  inflammatory  process  is  very  violent,  when  it  will  be 
well  to  wait  until  the  more  severe  symptoms  have  subsided,  as 
enucleation  m  panophthalmitis  is  attended   with  considerable 


356  DISEASES  AND  INJURIES  OF  THE  EYE. 

diiOficulty  and  danger,  as  it  may  result  fatally.  Tlie  severe 
cases  will  require  hot  applications  and  an  early  incision 
through  the  anterior  part  of  the  eyeball,  which  will  allow  of 
the  escape  of  the  lens  and  some  of  the  purulent  vitreous  and 
thus  mitigate  the  pain.  Attention  to  diet  will  be  necessary, 
and  if  the  condition  of  the  patient  requires  it,  a  full  allowance- 
of  nourishing  food,  and  perhaps  stimulants  to  sustain  the 
strength,  will  be  indicated.  When  the  disease  is  well  estab- 
lished but  little  can  be  done  with  remedies  beyond  preventing 
further  complications,  as  the  eyeball  is  almost  certain  to  be 
destroyed.  The  remedies  which  may  be  indicated  are 
Phytolacca,  Rhus  tox.,  Arsenicum,  Hepar  s.,  Merc,  Silicia,  or 
Sulphur,  in  the  order  given;  the  concomitant  symptoms,, 
more  than  the  special  indications,  deciding  the  choice. 

ScLEROTico-CHOKOiDiTis  POSTERIOR  has  been  considered 
when  speaking  of  myopia,  and  its  ophthalmoscopic  appearances- 
given.  When  progressive,  the  process  is  essentially  the  same 
as  that  of  disseminate  choroiditis. 

Other  clinical  forms  of  choroidal  disease  are  observed,  but 
of  much  less  importance;  of  these,  what  are  termed  colloid 
excrescences  merit  notice.  These  consist  of  minute  nodules, 
which  appear  like  mustard  seeds,  and  usually  spring  from  i  he 
lamina  vitrea,  the  internal  limiting  layer  of  the  choroid,  and 
extend  toward  the  retina,  displacing  and  causing  absorption  of 
the  retinal  pigment,  but  do  not  interfere  with  the  other 
layers  of  the  retina,  nor  do  they  afltect  the  choroidal  stroma  or 
interfere  with  vision.  In  rare  cases,  miliary  tubercles  are 
observed  scattered  through  the  choroid  and  are  a  constant 
accompaniment  of  acute  tuberculosis  and  present  a  very  similar 
appearance  to  colloid  excrescences,  although  the  masses  are 
larger,  being  about  one-third  or  one-half  the  diameter  of  the 
optic  disc,  and  generally  occur  beneath  the  pigment  layer  and 
present  a  hemispherical  shape,  with  the  summit  internal  and 
reflecting  the  light. 

Sarcoma  of  the  Choroid  is  the  only  variety  of  tumor  which 
has  its  origin  in  this  tissue;  when  rich  in  pigment  it  is  called 
melano-savGoma.     It  occurs  usually  late  in  life,  being  rarely 


DETACHMENT  OF  THE  CHOROID.  857 

seen  under  thirty-five  or  forty.  Defect  of  sight  is  often  the 
only  symptom  in  the  early  stages  of  the  growth,  but  sooner  or 
later  the  tension  becomes  increased,  and  pain  and  all  the 
symptoms  of  acute  or  sub  acute  glaucoma  appear.  The  tumor 
appears  as  a  brownish  rounded  mass  with  a  broad  base  and,  as 
it  grows,  pushes  the  retina  before  it.  Detachment  of  the 
retina  around  the  tumor,  either  from  hemorrhage  or  effusion, 
accompanies  the  gro-\vth,  and  in  the  early  stages  may  render 
the  diagnosis  uncertain,  but  soon  it  will  appear  through  the 
retina  and  will  be  distinguished  by  the  irregular  vessels  upon 
its  surface.  As  long  as  the  tumor  is  confined  to  the  interior 
of  the  eye,  the  growth  may  be  very  slow.  The  tumor,  after 
filling  the  eye,  will,  if  not  checked  by  removal,  soon  appear 
as  a  fungous  mass  between  the  lids,  or  involve  the  tissues  of 
the  orbit  and  the  brain. 

Treatment. — The  early  removal  of  the  tumor,  while  confined 
to  the  eyeball,  is  demanded,  for  if  enucleation  is  performed 
before  the  optic  ners-e  or  the  orbital  tissues  become  involved, 
the  prognosis  is  reasonably  good,  though  the  danger  of  secon- 
dary growths  in  the  more  distant  organs,  especially  the  liver, 
must  be  remembered. 

Detachment  of  the  Choroid  from  the  sclera  may  result 
from  injury,  the  growth  of  tumors,  or  from  collections  of  blood 
or  serum  behind  it,  and  may  be  mistaken  for  a  sarcomatous 
growth.  In  many  cases  the  sudden  effusion  beneath  the  cho- 
roid results  in  separation  of  its  tissue  or  rupture  of  the 
choroid^  which  allows  of  the  escape  of  the  fluid  into  the  vit- 
reous. 

CoLOBOMA  OF  THE  CHOROID  is  a  Congenital  absence  of  a 
portion  of  its  tissue  extending  from  the  optic  disc  to  the 
ciliary  body,  or  it  may  be  quite  small  and  confined  to  the  part 
around  the  nerve.  The  sclera  is  exposed,  and  with  the 
ophthalmoscope  the  coloboma  appears  as  an  extensive  atrophic 
spot  in  the  choroid.  It  is  almost  always  accompanied  by  a 
congenital  cleft  of  the  iris. 

Albinism  is  a  congenital  absence  of  the  pigment  layer  of 
the  retina  and  pigment  stroma  of  the  choroid,  as  well  as  of 


858  DISEASES  AND  INJURIES  OF  THE  EYE. 

the  ciliary  body  and  iris.  The  pupil  appears  pink  from  the 
light  being  transmitted  through  the  sclera.  Sight  is  defective 
and  such  patients  suffer  from  photophobia  and  nystagmus. 

Slight  relief    is  obtained  by  the  use  of   dark  glasses  to 
moderate  the  light 


CHAPTER    XIX. 
GLAUCOMA. 


The  word  glaucoma — derived  from  the  Greek  glaucos,  green 
— was  originally  applied  to  cases  of  loss  of  vision  accompa- 
nied by  a  greenish  color  of  the  pupil  due  to  turbidity  of  the 
vitreous. 

Since  the  ophthalmoscope  came  into  use,  the  term  glaucoma, 
while  only  expressing  an  occasional  condition  which  may  be 
presented  in  the  later  stages  of  the  diseased  condition,  is  still 
retained  but  is  now  understood  as  indicating  in  the  eye  the 
presence  of  a  certain  group  of  symptoms,  which  are  character- 
ized by  an  increased  fluid  tension  of  the  globe. 

The  definition  which  seems  to  cover  and  explain  the  group 
of  symptoms  to  which  the  term  is  now  restricted  is  this: — 
"  Glaucoma  is  the  expression  of  a  disturbance  in  the  equilib- 
rium between  secretion  and  excretion,  characterized  by  an 
increase  in  the  fluid  contents  of  the  eyeball." 

Glaucoma,  then,  consists  in  an  increased  tension  of  the 
globe,  which  leads  to  degenerative  changes  in  the  optic  nerve, 
retina,  choroid,  and  indeed  of  the  whole  of  the  interior  struc- 
tures of  the  eye  with  loss  of  function. 

Varieties. — Several  divisions  of  the  glaucomatous  process 
are  made  according  to  the  clinical  manifestations  of  the 
disease ;  practically,  however,  two  varieties  only  need  be  con- 
sidered, viz:  1,  acute  or  inflammatory;  and  2,  chronic  or  non- 
inflammatory. 


360  DISEASES  AND  INJURIES  OF  THE  EYE. 

ACUTE    OR    INFLAMMATORY    GLAUCOMA. 

The  term  acute  or  inflammatoiy  glaucoma  is  applied  to  that 
class  of  cases  where  there  is  an  inflammation  of  certain  struc- 
tures of  the  interior  of  the  eyeball,  associated,  with  great 
congestion,  consequent  increase  in  the  fluid  secretion  and 
accompanied  by  an  interruption  in  the  exit  of  -the  fluids  from 
the  eye.  I 

Causes.  —  The  primary  exciting  cause  is  commonly  an 
inflammation  of  the  iris,  or  cornea,  or  an  irido-choroiditis  of  a 
serous  nature.  It  quite  frequently  follows  injuries,  as  in 
punctured  wounds  of  the  cornea  with  rupture  of  the  lens 
capsule,  and  consequent  swelling  of  the  lens  substance  which 
presses  upon  the  iris  and  the  latter  interferes  with  the  fi'ee 
exit  of  fluid  at  the  angle  of  the  iris  into  the  canal  of  Schlemm. 
Again,  the  pressure  of  the  lens  upon  the  iris  may  cause  an 
iritis  which  blocks  up  the  channels  for  exit  of  the  fluid  and 
increases  the  tension.  Again  the  increased  tension  may  occur 
as  a  result  of  ulceration  and  perforation  of  the  cornea  when 
the  iris  has  prolapsed  into  the  opening.  During  or  after 
iritic  inflammations  which  have  caused  occlusion  of  the  pupil 
or  complete  adhesion  of  the  iris  to  the  surface  of  the  lens,  or 
after  cataract  operations  which  have  left  a  pupil  closed  by  a 
false  membrane.  Tumors  in,  or  even  upon  the  eye,  often  give 
rise  to  attacks  of  glaucoma.  When  occurring  from  these 
causes  it  is  termed  secondary  or  consecutive  glaucoma.  Acute 
inflammatory  glaucoma  may  arise  idiopathically,  or  occur  as 
an  acute  exacerbation  of  the  chronic  form. 

Symptoms  and  Diagnosis.  —  Acute  glaucoma  comes  on 
suddenly  and  the  first  symptoms  observed  are  increased  ten- 
sion and  ciliary  neuralgia.  The  globe  is  congested  from 
sub-conjunctival  injection,  the  anterior  ciliary  veins  are  promi- 
nent and  turgid.  The  iris  is  sluggish  in  movement  and  the 
pupil  dilated.  The  cornea  appears  dull,  its  epithelium  perhaps 
punctated,  and  there  is  some  loss  of  sensibility.  The  aqueous 
and  vitreous  are  turbid  and  ophthalmoscopic  examination 
impossible.  The  diagnosis  of  increased  tension  when  the  lids 
are    swollen   becomes   difficult    and   often    impossible.      The 


ACUTE  OR  INFLAMMATORY  GLAUCOMA.  361 

Tision  which  before  may  have  been  good,  now  becomes 
markedly  decreased.  The  diagnostic  feature  is  the  increased 
tension  which  is  readily  detected  upon  palpation. 

Acute  glaucoma  may  be  confounded  with  iritis,  as  the 
scleral  congestion,  dilated  pupil,  and  shallow  anterior  cham- 
ber and  periorbital  neuralgia  may  be  present  in  both.  The 
injection  together  with  the  pain  which  may  be  referred  to  the 
whole  side  of  the  head,  and  the  constitutional  disturbance  may 
also  lead  one  to  mistake  the  attack  for  one  of  cerebral  trouble, 
but  the  close  inspection  of  the  eye  and  the  testing  of  the  vision 
will  remove  any  doubt.  The  attack  may  arise  without  warning 
during  the  night  and  intense  pain  in  the  eye,  forehead,  or 
temple,  be  the  first  symptom  complained  of.  Injection  of  the 
ocular  conjunctiva  rapidly  appears  and  chemosis  and  swelling 
of  the  lids  follow.  The  iris  is  discolored  and  dilated,  and  the 
anterior  chamber  shallow.  The  aqueous  becomes  turbid  and 
the  cornea  hazy  and  no  satisfactory  inspection  of  the  fundus 
can  be  made  Avith  the  ophthalmoscope.  The  vision  is  rapidly 
impaired  or  wholly  lost  within  a  few  hours.  The  condition 
may  exist  for  a  few  hours  and  the  symptoms  rapidly  disappear 
and  the  vision  return.  Again  the  attack  may  not  subside  for 
several  days  and  the  sight  be  entirely  destroyed.  Cases  where 
the  attack  comes  on  suddenly  and  is  accompanied  by  severe 
constitutional  disturbance,  with  complete  loss  of  vision  from 
the  start,  have  received  the  name  of  glaucoma  fulminans. 

Tkeatment. — When  the  glaucomatous  condition  occurs  after 
injury,  prompt  measures  must  bo  used  to  relieve  the  fluid 
pressure,  by  paracentesis  of  the  cornea,  or  when  a  swollen  lens 
is  the  exciting  cause  it  will  be  necessary  to  extract  it.  In 
other  cases  when  the  iris  is  not  adherent  to  the  lens  tempo- 
rary relief  may  be  obtained  by  the  use  of  a  solution  of  eserine 
to  contract  the  pupil.  Finally,  it  will  be  necessary  to  make 
an  iridectomy  if  the  tension  is  not  lessened  by  other  means. 

CHRONIC  GLAUCOMA. 

In  glaucoma  simplex  or  chronic  glaucoma  we  find,  as  a  rule, 
two  stages  presented,  the  so-called  premonitory  and  the  con- 
firmed conditions. 


362 


DISEASES  AND  INJURIES  OF  THE  EYE. 


The  premonitory  stage  of  glaucoma  which  may  precede 
confirmed  glaucoma  by  a  period  varying  from  a  few  weeks  or 
months  to  several  years,  is  characterized  by  the  early  appear- 
ance of,  or  the  rapid  increase  of  the  existing,  presbyopia, 
which  requires  repeated  changes  of  glasses  for  near  work. 
Halos  or  colored  rings  appear  from  time  to  time  around  the 
candle  or  artificial  lights,  and  the  field  of  vision  is  more  or 
less  contracted  at  times,  or  the  vision  is  obscured  and  foggy, 
and  the  patient  complains  of  the  appearance  of  smoke  before 
the  eyes.  The  tension  of  the  eyeball  is  more  or  less  increased, 
the  retina  hypersemic,  and  the  arteries  are  seen  to  pulsate 
when  viewed  by  the  ophthalmoscope,  or  pulsation  is  easily 
produced  in  them  by  light  pressure  of  the  finger  upon  the  ball. 
These  symptoms,  except  the  presbyopia,  which  remains 
increased,  are  presented  from  time  to  time  and  last  from  a  few 
moments  to  several  hours,  and  then  pass  off  and  the  vision 
again  becomes  normal.  The  periods  of  remission  become 
shorter  and  shorter  and  after  a  few  months  or  a  year,  very 
rarely  longer,  these  prodromal  attacks  are  succeeded  by  the 
confirmed  condition. 

Causes. — The  causes  of  non-inflammatory  or  chronic  glau- 
coma are  as  yet  not  fully  known.  It  may  follow  upon  one  or 
more  attacks  of  acute  glaucoma.  It  is  rarely  obsers^ed  under 
thirty  years  of  age  and  occurs  usually  at  or  about  the  age  of 
fifty  years.  Certain  races  (Jews)  and  particular  families 
seem  prone  to  the  disease  oA\dng  to  a  want  of  elasticity  of  the 
sclera,  others  (Arabs)  enjoy  immunity  from  it  owing  to 
remarkable  suppleness  of  the  membranes  and  the  absence  of 
fatty  degenerations  at  any  age.  Sex  seems  to  have  no  bearing 
upon  the  etiology  of  the  disease,  although  women  seem  to  be 
more  liable  to  it  than  men.  It  occurs  more  frequently  in 
hyperopic  than  in  myopic  eyes.  Neuralgias  of  the  fifth  nerve, 
degenerative  changes  and  hemorrhages  in  the  retina,  and 
adhesions  of  the  iris  and  changes  in  the  anterior  portions  of 
the  eye  which  tend  to  keep  up  an  irritable  condition  of  the 
eye,  are  liable  in  elderly  people  to  produce  glaucoma.  Among 
other  exciting  causes,  mental  anxiety  and  loss  of  sleep  may  be 


CHRONIC  GLAUCOMA.  363 

mentioned.     The  use  of  atropine  seems  sufficient  to  excite  a 
glaucomatous  condition  in  some  eyes. 

The  theories  as  to  the  local  cause  of  the  increased  tension 
are  various,  and  seem  to  satisfactorily  explain  the  condition  in 
individual  cases  and  it  is  not  probable  that  the  glaucomatous 
condition  is  due  to  the  same  cause  in  all  cases.  Whatever 
the  productive  cause  may  be  it  is  aided  by  the  loss  of  distensi- 
bility  which  the  sclera  always  undergoes  with  advancing  age. 
The  theory  of  Donders,  that  there  is  primarily  a  neurosis  of 
the  fifth  nerve  which  occasions  a  hypersecretion  of  the  intra- 
ocular fluids,  well  explains  the  glaucomatous  symptoms  in  some 
cases.  In  the  majority  of  cases  the  condition  is  undoubtedly 
due  to  the  obstructions  of  the  exits  of  the  fluids  from  the  eye. 
Eecent  pathological  researches  have  shown  such  obstructions 
to  exist  from  morbid  changes  near  the  attachment  of  the  iris, 
ciliary  muscle  and  canal  of  Schlemm  which  would  impede  the 
escape  of  fluid  from  the  anterior  chamber.  Again  the  open- 
ings in  the  ligamentum  pectinatum  at  the  angle  of  the  iris 
have  been  found  filled  with  plastic  exudation,  or  obliterated, 
and  as  the  major  portion  of  the  fluid  which  has  been  used  to 
nourish  the  interior  structures  of  the  eye,  together  with  that 
secreted  by  the  surface  of  the  iris,  passes  through  this  porous 
structure  to  reach  the  canal  of  Schlemm,  any  interference 
with  the  normal  removal  of  the  fluid  must  result  in  increased 
tension.  The  increase  of  tension  which  may  arise  from  these 
causes  may  be  slight  at  first,  but  tends  to  interfere  still  more 
with  the  exit  of  fluid  through  the  natural  outlets  and  if  it 
persists  for  any  length  of  time  produces  changes  in  the  deli- 
cate structures  of  the  eye  from  pressure,  or  precipitates  an  acute 
inflammatory  attack.  Changes  in  the  oblique  channels  in  the 
sclera  which  give  passage  to  the  venae  vorticosse,  may  also  by 
obstructing  the  flow  of  venous  blood,  occasion  an  increase  of 
tension  in  the  posterior  chamber  which  may  rapidly  involve 
that  of  the  whole  eye.  The  same  condition  may  arise  in  cases 
of  complete  adhesion  of  the  iris  to  the  lens  which  prevents 
the  passage  of  the  nutritive  fluids  from  the  vitreous  into  the 
anterior  chamber. 


364  DISEASES  AND  INJURIES  OF  THE  EYE. 

•  Results  of  Pressure. — The  immediate  effect  of  increased 

tension  of  the  eyeball  is  to  lower  the  functional  activity  of  the 
Tetina  by  retarding  the  circTilation  of  the  blood  through  it 
When  the  retinal  vessels  can  be  seen  in  glaucoma  the  arteries 
-are  narrowed  and  perhaps  pulsating  while  the  veins  are  tortu- 
ous and  full.  The  contraction  of  the  visual  field  occurs  from 
the  greater  resistance  which  must  be  overcome 
by  the  circulation  to  reach  the  peripheral  portions 
of  the  retina.  If  the  fluid  pressure  continues  for 
a  time  the  optic  nerve  fibres  suffer  from  stretch- 
ing and  atrophy.  The  lamina  cribrosa  which 
forms  the  floor  of  the  disc,  being  the  weakest  part 
of  the  ocular  envelope,  is  pressed  backward  by  the 
pressure  of  the  increased  fluid,  the  soft  fibres  of 
FIG.  142.  the  optic  nerve  are  pressed  upon  in  the  same 
manner  and  ultimately  atrophy.  The  result  is  that  the  disc 
becomes  not  only  atrophied,  but  depressed  or  excavated  as 
in  Fig.  142.  This  depression  or  excavation  constitutes  the 
glaucomaious  cup  which,  when  deep,  presents  steep  or  over- 
hanging edges. 

Symptoms  and  Diagnosis. — The  chronic  variety  of  glaucoma 
is  distinguished  from  the  acute  form  by  its  slower  and  more 
insidious  progress.  One  eye  alone  may  be  affected  but  sooner 
or  later  the  other  becomes  involved.  As  has  already  been 
stated  it  may  follow  upon  one  or  more  acute  attacks,  or  exhibits 
the  symptoms  of  the  premonitory  stage,  the  most  important  of 
which  is  the  premature  development  or  rapid  increase  of  the 
presbyopia.  The  pain  is  less  violent  than  in  the  acute  attacks, 
and  the  conjunctival  injection  less  marked  or  absent,  but  there 
is  a  marked  turgidity  of  the  anterior  ciliary  veins.  The  iris  is 
sluggish  in  movement  and  the  pupil  dilated,  often  to  its  full 
extent.  The  cornea  appears  normal  or  may  be  dull  and  often 
more  or  less  insensible  to  touch.  The  sclera  often  presents  an 
unnatural  whiteness  which  makes  the  tortuous  veins  more 
prominent  The  anterior  chamber  may  be  normal  or  shallow, 
«,nd  the  iris  and  lens  pressed  forward.  The  characteristic 
signs,  however,  are  increased  intra-ocular  tension,  excavation 


CHRONIC  GLAUCOMA.  365 

of  the  optic  papilla  and  the  regularity  ^^dth  which  the  pressure 
acts  upon  the  retina,  fii'st  limiting,  and  eventually  destroying 
the  field  of  vision. 

Increased  tension,  and  sluggishness  vnih.  slight  or  full  dilata- 
tion of  the  pupil  are  more  valuable  as  diagnostic  signs  than 
the  excavation  of  the  disc,  as  the  latter  may  be  present  as  a 
physiological  condition.  If,  however,  we  have  pressure-exca- 
vation the  veins  appear  flattened  and  dilated  at  the  edge  of  the 
excavation  (as  in  Fig.  143  Avhich  shows  the  ophthalmoscopic 
appearance  of  the  glaucomatous  cupping),  and  arterial  pulsa- 
tion will  be  produced  by  slight 
pressure  of  the  finger  upon  the 
eyeball.  The  final  confirmatory 
symptom,  after  palpation  and  the 
evidences  of  pressure  upon  the 
papilla,  is  the  condition  of  the 
sensibility  and  circulation  of  the 
retina.  Central  vision  is  only 
slightly  impaired  at  first,  but  the 
field  of  vision  is  found  contracted, 
^^^•^*^'  the  inner  or  nasal  side  suffering 

first,  then  the  inferior  and  superior  portions  in  turn,  until 
only  a  narrow  slit,  widening  outward,  is  left,  and  the  sight 
may  remain  relatively  good  as  long  as  the  narrow  end  of  the 
slit  has  not  passed  beyond  the  point  of  fixation.  When  there 
is  concentric  limitation  of  the  field  of  vision,  and  the  field  of 
colors  but  little  disturbed,  the  loss  of  vision  is  due  to  pressure- 
excavation  and  not  to  nerve  atrophy.  With  this  condition  the 
patient  is  liable  to  acute  inflammatory  attacks  which  supervene 
upon  such  exciting  causes  as  over-use  of  the  eyes,  mental 
emotions,  over-indulgence  in  stimulants,  or  any  cause  which 
may  increase  the  ocular  congestion.  Any  one  of  these  attacks 
may  destroy  the  vision  completely. 

When  the  glaucomatous  condition  has  existed  for  a  long 
time  and  there  is  permanent  increased  tension  with  total  losa 
of  vision,  degenerative  changes  result  and  the  term  absolute 
glaucoma  is  applied.    The  anterior  chamber  is  shallow,  the  iris 


366  DISEASES  AND  INJURIES  OF  THE  EYE. 

widely  dilated  and  atrophied,  the  lens  transparent,  or  catarac- 
tous,  and  the  pupil  greenish.  If  the  media  are  clear  the 
ophthalmoscopic  examination  shows  deep  cupping  of  the 
nerve,  absence  of  capillaries  and  lessening  and  disappearance 
of  the  arteries,  and  turgid  veins.  There  is  frequently  constant 
or  paroxysmal  pains  in  and  about  the  eye. 

Differential  Diagnosis. — The  chronic  form  of  glaucoma, 
being  insidious  in  its  approach,  forms  one  of  the  most  frequent 
causes  of  preventible  blindness,  as  it  often  goes  undetected 
until  the  vision  is  to  a  great  degree  lost,  and  occurring  as  it 
does  in  patients  of  fifty  years  or  more,  it  is  too  readily 
attributed  to  failure  of  vision  from  old  age.  The  patient, 
however,  finding  there  is  no  permanent  improvement  of  vision 
from  the  frequent  changes  of  spectacles  which  he  has  made, 
calls  the  attention  of  his  medical  attendant  to  his  failing  vision. 
Here  the  disease  is  frequently  not  recognized  and  more 
frequently  mistaken  for  one  of  cataract,  owing  to  a  smoky 
appearance  of  the  lens  in  the  pupil,  and  the  patient  is  advised 
to  wait  until  the  cataracts  are  mature  when  he  can  be  operated 
upon  with  restoration  of  his  vision.  Reassured  by  the  ad-\  ice 
of  his  physician  he  watches  his  vision  disappear  from  week  to 
week  until  the  sight  in  one  or  both  eyes  is  reduced  to  simple 
perception  of  light,  and  is  then  sent  to  the  oculist  who  in  turn 
finds  that  the  opportunity  for  the  practice  of  Yon  Graefe's 
brilliant  discovery  has  passed,  and  the  patient  returns  to  his 
home  hopelessly  blind. 

Like  cataract  the  disease  is  usually  symmetrical  and  one 
eye  may  be  affected  a  longer  or  shorter  interval  before  the 
other.  It  occurs,  as  does  senile  cataract,  generally  in  patients 
considerably  past  middle  life,  unless  arising  from  injury  or 
secondary  to  inflammatory^  changes  in  the  structures  of  the  eye, 
when  we  may  have  it  appearing  as  does  cataract  at  any  age. 

Like  cataract  there  may  be  the  gradual  failure  of  sight,  this 
loss  of  vision  being  frequently  attributed  to  senile  changes. 
The  reduction  of  central  vision,  however,  is  not  as  frequent  as 
the  impairment  of  the  field  of  vision  particularly  on  the  nasal 
side.     There  are,  not  unfrequently,  periods  of  blindness  last- 


CHRONIC  GLAUCOMA.  367 

ing  from  a  few  minutes  to  a  few  hours,  in  cases  of  chronic 
glaucoma;  these  attacks  may  occur  with  little  or  no  pain,  the 
pain  when  present  being  referred  to  the  eyebrow  or  forehead. 

With  cataract  the  halo  about  the  source  of  illumination  may 
appear,  rarely  the  colored  fogs  or  rainbow  tints  as  in  some 
cases  of  glaucoma. 

With  glaucoma  we  have  a  rapid  increase  of  the  existing 
presbyopia,  that  is  the  patient  is  no  longer  able  to  read  at  his 
usual  distance  with  his  glasses,  but  must  hold  his  paper  further 
from  him,  and  changes  his  glasses  for  still  stronger  ones  to 
keep  pace  with  the  increasing  weakness  of  the  ciliary  muscle, 
until,  finally,  he  finds  even  with  the  strongest  glasses  his  vision 
is  not  improved.  The  cataract  patient  also,  as  he  finds  his 
vision  failing,  changes  his  glasses  but  gets  no  improvement, 
as  the  fault  lies  not  in  the  paresis  of  the  accommodation  but 
in  the  loss  of  transparency  of  the  crystalline  lens.  On  exami- 
nation of  the  eye,  we  find  in  the  glaucomatous  case,  a  dilatation 
and  sluggish  condition  of  the  pupil,  whereas  in  cataract  we 
have  the  pupil  normal  or  contracted  as  in  the  aged. 

Again  the  cataract  patient  will  tell  you  that  his  sight  is 
better  in  the  evening  or  by  shading  the  eyes  with  the  hand, 
while  the  vision  in  glaucoma  is  not  improved  in  this  way. 

We  also  notice  that  in  glaucoma  with  the  dilatation  of  the 
pupil,  we  have  a  shallow  anterior  chamber,  the  cornea  flattened 
and  frequently  showing  loss  of  sensibility.  With  cataract  we 
have  the  anterior  chamber,  the  curvature  and  sensation  of  the 
cornea  normal. 

With  glaucoma  we  may  have  a  steamy  or  ground  glass 
appearance  of  the  cornea,  which  in  cataract  is  transparent. 
With  oblique  illumination  we  discover  at  once  the  opacity  of 
the  lens  in  cataract,  and  in  glaucoma  we  frequently  find  an 
apparent  haziness  of  the  lens,  which  is  not  necessarily  the 
result  of  the  disease,  or  if  the  intra-ocular  tension  has  existed 
for  some  time,  we  may  find  cataract  resulting  from  the  glauco- 
matous condition.  The  ophthalmoscope  shows  in  glaucoma 
hypersemia  and  cupping  of  the  optic  disc,  and  spontaneous  or 
easily  producible  pulsation  of  the  retinal  arteries.     In  cataract 


368  DISEASES  AND  INJURIES  OF  THE  EYE. 

vre  are  unable  to  obtain  a  view  of  the  fundus  as  the  view  is 
arrested  by  the  loss  of  transparency  in  the  lens  and  not  from 
turbidity  of  the  vitreous. 

Finally,  as  has  already  been  stated,  with  cataract  we  have 
no  attendant  pain,  with  glaucoma  we  may  have  pain  or  inflam- 
mation. With  cataract  the  tension  of  the  eyeball  obtained  by 
the  sense  of  touch,  gives  no  sensible  resistance;  in  glaucoma, 
however,  the  sense  of  hardness  becomes  apparent  at  once  if 
the  tension  is  great,  and  in  case  of  doubt,  it  should  be  com- 
pared with  that  of  the  normal  eye. 

Treatment. — In  the  prodromal  stage  the  operation  of  iri- 
dectomy is  not  indicated,  unless  the  patient  is  likely  to  be  lost 
sight  of,  or  when  decided  hardness  of  the  globe  remains  after 
the  attack  has  passed  off.  Every  precaution  should  be  taken 
to  prevent  cerebral  and  ocular  congestion.  Light  smoke-col- 
ored protective  glasses  should  be  used.  All  excesses  of  either 
eating  or  drinking  should  be  strictly  enjoined.  Sleep  imme- 
diately after  a  full  meal  should  be  forbidden  and  the  use  of 
strong  tea  or  coffee  stopped.  The  eyes  should  not  be  exposed 
to  bright  lights,  cold  winds  or  dust.  Any  causes  of  ill-health 
should  be  carefully  investigated  and  removed  if  possible,  and 
the  endeavor  made  to  put  the  patient  in  a  good  condition.  If 
the  vision  becomes  impaired  or  the  glaucomatous  condition 
becomes  confirmed,  or  inflammatory  symptoms  supervene  an 
iridectomy  should  be  made  at  once. 

For  the  chronic  or  confirmed  glaucoma  the  only  kno^va 
remedy  which  seems  at  all  beneficial  is  iridectomy.  The  dis- 
covery of  Von  Graefe,  that  the  removal  of  a  large  section  of 
the  iris  was  capable  of  lessening  the  intra-ocular  tension  and 
curing  in  many  cases  the  glaucomatous  condition,  will  ever 
cause  his  name  to  be  held  in  the  highest  honor,  for  the  means 
thus  afforded  of  saving  a  great  many  eyes  from  absolute 
blindness.  Tlie  operation  of  iridectomy,  however,  is  not  the 
only  remedy  we  haA'e  for  the  condition,  but  it  properly  heads 
the  list,  and  if  prompt  relief  is  not  obtained  from  other 
measures  no  hesitancy  should  cause  any  delay  in  the  perform- 
ance of  the  operation. 


CHRONIC  GLAUCOMA.  369 

Of  homoeopathic  remedies,  Bell.,  Bry.,  Colocynfh,  Gels.; 
Prunus,  and  Phosph.,  have  been  of  undoubted  benefit  in  the 
pi-emonitory  stage,  and  have  a  marked  action  in  relieving  the 
pains  and  periodical  exacerbations. 

The  local  use  of  eserine  solution  diminishes  the  tension  of 
some  cases  of  glaucoma  and  in  a  few  cases  has  proved  useful. 

The  severe  pain  which  is  present  during  exacerbations  of 
the  glaucoma  may  be  somewhat  mitigated  by  the  use  of  hot 
moist  applications  to  the  eye  and  if  the  pain  is  intense  it  will 
be  necessary  to  prescribe  an  opiate. 

Iridectomy  cures  glaucoma  by  the  permanent  reduction  of 
the  tension  which  follows  the  operation;  the  rationale  of  its 
action,  however,  is  not  yet  understood,  yet  no  doubt  can  be 
entertained  of  its  curative  properties  and  the  delay,  sometimes 
of  only  a  few  hours,  to  perform  the  operation  when  there  is 
increased  tension  may  produce  irreparable  blindness.  In  order 
that  iridectomy  may  produce  a  lessening  of  the  tension  of  the 
eyeball  a  large  segment,  at  least  a  quarter  or  ev^en  a  third  of 
the  iris  must  be  removed,  and  it  must  be  taken  away  quite  up 
to  its  ciliary  attachment,  a  result  which  is  better  attained  by 
two  or  three  sections  with  the  scissors,  than  with  only  one  clip 
as  in  an  ordinary  iridectomy.  The  incision  should  be  made  in 
the  cornea  close  to  the  sclero-comeal  junction  and  in  a  direction 
parallel  to  the  plane  of  the  iris.  The  modus  operandi  of  the 
operation  has  already  been  given  on  page  287.  The  following 
rules  are  to  be  considered  in  deciding  upon  the  necessity  for 
the  performance  of  an  iridectomy  in  glaucoma. 

No  iridectomy  is  to  be  performed  in  the  premonitory  stage 
of  glaucoma  as  long  as  the  field  of  vision  is  not  contractecL 
When  acute  inflammatory  symptoms  appear  in  an  eye  which 
has  exhibited  increased  tension  an  operation  should  be  made 
without  delay. 

When  the  chronic  condition  exhibits  more  or  less  inflamma- 
tory tendency  the  performance  of  an  iridectomy  afibrds  the 
patient  the  only  chance  of  saving  his  vision.  There  is  a  form 
of  glaucoma  which  is  marked  by  stony  hardness  of  the  eye- 
ball after  a  few  hours  with  complete  loss  of  vision  and  yet 

24 


370  DISEASES  AND  INJURIES  OF  THE  EYE. 

without  inflammation,  the  glaucoma  maligna  of  Von  Graefe, 
in  which  iridectomy  is  constantly  followed  by  intra-ocular 
hemorrhage.  Here  it  is  not  wise  to  make  an  iridectomy. 
Again  the  operation  of  iridectomy  is  contra-indicated  in  those 
cases  of  increased  eyeball-tension  which  exhibit  hemorrhages 
in  the  retina  or  choroid,  the  glaucoma  hemorrhagica.  The 
operation  of  iridectomy  also  seems  to  precipitate  an  attack  of 
acute  glaucoma  in  the  other  eye,  but  the  cases  which  are  likely 
to  be  followed  by  such  disastrous  results  are  not  determinable 
before  operating.  Among  the  other  measures  which  have  been 
proposed  and  used  for  the  relief  of  glaucoma 
are  sclerotomy  and  myotomy,  trephining  the 
sclera,  and  the  insertion  of  a  gold  wire  suture 
through  the  sclera.  Of  these  the  only  one 
which  has  proved  of  value  as  a  substitute  for 
iridectomy  is  the  operation  of  sclerotomy 
which  is  performed  in  the  following  manner. 
FIG.  144.  The  pupil  is  to  be  well  contracted  by  the  instil- 

lation of  eserine  and  a  linear  cataract  knife  introduced  on  the 
temporal  side  one  millimetre  behind  the  sclero-corneal  junc- 
tion, and  three  millimetres  above  the  horizontal  meridian.  The 
point  of  the  knife  is  carried  slightly  forwards,  in  front  of  the 
iris,  pushed  across  and  brought  out  at  a  point  exactly  opposite 
to  its  entrance.  The  incision  is  made  slowly  upward,  close  in 
front  of  and  parallel  to  the  plane  of  the  iris,  until  the  edge  of 
the  knife  reaches  the  upper  portion  when  it  is  directed  slightly 
forward  and  the  aqueous  allowed  to  drain  off,  a  bridge  of 
uncut  sclera  is  left  and  the  knife  slowly  withdrawn,  a  solution 
of  eserine  introduced  and  a  bandage  applied.  The  relative 
positions  of  the  incisions  for  iridectomy  (7)  and  sclerotomy 
(/S)  are  shown  in  Fig.  14:4 

After  either  of  these  operations  the  wound  sometimes  closes 
imperfectly,  and  a  cysioid  cicatrix  is  formed.  In  these  cases 
the  wound  generally  closes  after  the  operation,  but  after  a 
time  the  ocular  tension  increases  and  the  scar  tissue  being 
more  distensible  than  other  portions  of  the  sclera,  bulges  out. 
Often  the  cicatricial  tissue  is  so  loose  that  the  aqueous  filters 


CHRONIC  GLAUCOMA.  371 

through  it  and  collects  beneath  the  conjunctiva  in  the  shape  of 
a  large  vesicle,  which  may  cause  much  irritation  or  even 
inflammation,  which  may  destroy  the  eye.  The  collection 
should  be  removed  by  pricking  it  with  the  point  of  a  needle, 
and  a  compress  bandage  then  applied  to  encourage  healing. 

The  curative  value  of  either  iridectomy  or  sclerotomy  is 
greatest  in  acute  cases ;  when  the  operation  is  performed  imme- 
diately a  complete  cure  generally  results.  In  sub-acute  cases 
with  limitation  of  the  field  of  vision,  the  improvement  is  very 
slow.  In  the  chronic  conditions  slight  improvement  or  the 
preservation  of  the  remaining  sight  is  deemed  a  good  result. 
If  the  tension  returns  after  an  operation  has  been  made  it  will 
be  necessary  to  repeat  it,  and  the  iridectomy  made  opposite 
the  first. 

If  the  vision  is  entirely  destroyed  by  the  prolonged  pres- 
sure, no  benefit  will  be  derived  from  an  operation,  beyond  the 
relief  of  the  pain  which  may  present.  In  very  painful  cases, 
when  the  condition  is  one  of  absolute  glaucoma,  enucleation 
may  be  demanded  for  the  relief  of  the  pain. 

If,  as  sometimes  happens,  the  performance  of  an  iridectomy 
upon  one  eye  hastens  the  outbreak  of  the  glaucomatous 
condition  in  the  other,  the  second  eye  should  be  operated  upon 
"without  delay. 


CHAPTER     XX.  > 

DISEASES  OF  THE  RETINA. 

ANATOMY.  ^ 

The  retina  is  a  delicate  membrane  which,  contains  the 
terminal  filaments  of  the  optic  nerve.  Externally  it  lies  upon 
the  choroid,  while  internally  the  hyaloid  membrane  separates 
it  from  the  vitreous.  It  extends  from  the  optic  disc  forward 
to  the  ciliary  processes  where  it  ends  in  an  indented  border, 
the  ora  serrata.  From  this  portion  there  is  continued  forward 
on  the  ciliary  processes  a  fine  layer  of  transparent  nucleated 
cells  of  columnar  epithelium,  which  constitutes  the  ciliary 
portion  of  the  retina,  or  the  2^<^i^^s  ciliaris  retince,  which  dis- 
appears as  the  ciliary  body  passes  into  the  iris.  In  th& 
extent  of  the  retina  forward  its  thickness  diminishes  from 
-^  to  ^^  of  an  inch.  In  the  axis  of  the  eyeball  is  what  is 
termed  the  yellow  spot,  or  macula  luiea,  somewhat  elliptical 
in  shape  and  about  -^-^  of  an  inch  in  diameter ;  in  the  centre  of 
this  is  a  slight  depression,  the  fovea  centralis.  To  the  inner 
side  of  the  macula  is  the  white  or  pinkish  disc  which  marks 
the  entrance  of  the  optic  nerve  into  the  interior  of  the  eye. 
Around  the  optic  disc  the  retina  is  slightly  elevated,  and  from 
the  centre  of  the  disc  come  the  retinal  vessels  which  branch 
above  and  below  and  radiate  in  all  directions  to  supply  th© 
inner  layers  of  the  retina.  Near  the  macula  lutea  vessels 
sweep  off  above  and  below  (see  Fig.  6,  p.  11),  and  leave  thia 
region  free  of  the  larger  vessels.       The  arrangement  of  the. 


ANATOMY  OF  THE  RETINA. 


373 


capillary  vessels  in  the  macula,  and  their  absence  from  the 
fovea,  is  well  shown  in  Fig.  145.  In  the  normal  state  the 
retina  is  transparent  and  of  a  pinkish  color,  but  after  death 
it  soon  becomes  opaque. 

In  the  detailed  examination  of  the  retina  (Fig.  146),  ten 
layers  are  found,  which,  beginning  with  the  inner  surface  of 

the  retina,  are  described  as 
follows:  1,  membrana  lim- 
itans  interna,  a  thin  struc- 
tureless membrane  which 
separates  the  retina  from  the 
hyaloid;  2,  a  layer  of  optic 
nerve  fibres;  3,  a  layer  of 
ganglionic  cells;  4,  an  in- 
ternal granular  or  molecular 
FIG.  W5.  layer;  5,  an  internal  layer  of 

granules  or  nucleus-like  bodies,  of 
three  or  four  kinds;  6,  an  external 
granular  layer;  7,  external  granules;  8, 
membrana  limitans  externa;  9,  a  layer 
of  rods  and  cones;  10,  pigment  layer. 
In  addition  to  these  stratified  layers 
certain  fibrous  structures  are  seen, 
which  pass  through  the  retina  and  con- 
nect the  difi'erent  layers  and  really  form 
the  tissue  skeleton  of  the  retina.  These 
have  been  termed  the  supporting  fibres 
of  Mueller.  Of  the  ten  layers  named, 
some  are  characterized  as  belonging  to 
the  nerve  terminations,  as  the  2nd, 
optic  nerve  fibres ;  3rd,  ganglionic  cells ; 
5th,  inner  granules ;  7th,  outer  granules ; 
9tli,  the  rods  and  cones.  The  remain- 
ing layers,  except  the  pigment  cells,  are  supposed  to  form 
the  supporting  structure  of  the  retina  and  consist  mainly  of 
connective  tissue.  The  layer  of  rods  and  cones,  which  con- 
stitutes the  terminal  elements  of  the  optic  ners'e  fibres,  are 


FIG.  146. 


i^74  DISEASES  AND  INJURIES  OF  THE  EYE. 

of  special  interest.  The  rods  have  an  elongated  cylindrical 
form,  while  the  cones  are  much  shorter  and  thicker  and  are 
terminated  by  a  thinner  and  more  tapering  process.  The  rods 
and  cones  are  closely  set  together,  but  are  not  equally  dis- 
tributed over  the  expanse  of  the  retina;  at  the  more  peripheral 
portions  of  the  retina,  the  rods  far  outnumber  the  cones,  while 
at  the  macula  lutea  only  cones  are  found.  The  pigment  layer 
consists  of  flat,  hexagonal,  epithelial  cells  (Fig.  147),  which  are 
filled  with  brownish  pigment,  and  on  the  surface  towards  the 
choroid  are  smooth,  while  from  the  inner  surface  prolongations 
of  pigment  extend  between  the  processes  of  the 
rods  and  cones.  It  is  this  layer  which  is  sup- 
posed to  be  the  active  agent  in  the  secretion 
of  the  visual  purple.  At  the  macula  lutea,  the 
most   sensitive   portion   of   the   retina,    where 

FIG.  U7.  ... 

direct  Adsion  occurs,  the  relation  of  the  layers 
of  the  retina  is  somewhat  different.  All  the  layers  except  the 
2nd  (optic  nerve  fibres),  which  is  absent,  are  thickened  and 
only  cones  are  found,  while  at  the  fovea  all  the  layers  are  very 
much  thinned,  so  that  only  the  7th  layer,  with  the  cones  of 
the  9th,  can  be  demonstrated,  the  cones  here  being  crowded 
together  and  their  bodies  somewhat  thinned. 

The  blood  supply  and  lymph  spaces  of  the  retina  have  been 
considered  in  the  chapter  on  the  general  anatomy  of  the  eye. 
The  retinal  blood-vessels  are  found  only  in  the  inner  layers, 
the  more  external  layers  undoubtedly  deriving  their  supply  of 
nourishment  from  the  choroid.  The  ophthalmoscopic  appear- 
ances of  the  healthy  retina  (Plate  V,  Fig.  1)  are  negative, 
inasmuch  as,  the  retina  being  transparent,  nothing  of  its 
tissue  is  seen  except  the  blood-vessels,  but  we  must  be  familiar 
"with  their  normal  appearance  if  we  would  be  able  to  diagnose 
the  pathological  changes  which  may  occur  in  the  retina.  The 
arteries  are  of  a  light  red  color,  smaller  in  calibre  and 
straighter  than  the  veins,  which  are  dark  red,  larger  and  more 
tortuous.  The  optic  disc  is  easily  distinguished  by  its  white 
appearance  from  the  surrounding  retina,  and  occasionally  fine, 
grayish  lines  may  be  seen  radiating  from  the  disc,  which  mark 


DISEASES  OF  THE  RETINA.  375 

the  distribution  of  the  nerve  fibres.  In  rare  cases  these  lines 
are  very  marked,  and  white,  striated  masses  may  be  seen 
extending  some  distance  out  from  one  side  of  the  disc  or 
partially  encircling  it  and  giving  to  it  an  irregular  outline. 
This  is  a  congenital  condition,  and  the  appearance  is  due  to  a 
greater  or  less  number  of  the  nerv^e  fibres  passing  through  the 
lamina  cribrosa  and  still  retaining  their  medullary  sheaths 
and  appearing  in  the  retina  as  opaque  optic  nerve  fibres.  The 
macula  lutea  is  difficult  to  distinguish  from  other  portions  of 
the  retina,  except  in  children,  unless  the  pupil  is  well  dilated; 
it  appears  as  a  slightly  defined  grayish  circular  reflection  with 
a  central  whitish  dot  indicating  the  position  of  the  fovea. 

DISEASES  OF  THE  RETINA. 

Hyperemia  of  the  Retina. — Hypersemia  of  the  Retina  is 
very  difficult  of  recognition  as  the  congestion  of  the  vessels 
must  be  very  marked  to  enable  us  to  diagnose  the  condition. 
The  vessels  appear  darker  and  more  tortuous  and  the  optic 
disc  is  more  wa\y  in  appearance  and  there  may  be  slight 
clouding  of  the  retina  around  the  disc. 

Causes. — It  may  be  a  transient  condition  depending  upon 
over-use  of  the  eyes,  particularly  in  hyperopes  and  myopes,  or 
result  from  the  irritation  of  foreign  bodies  lodged  in  the 
cornea,  or  mental  emotions,  prolonged  weeping,  inflammatory 
afi'ections  of  other  portions  of  the  eye,  or  accompany  some 
derangement  of  the  general  circulation  or  of  the  digestive 
organs. 

Symptoms. — The  complaints  are,  usually,  flashes  of  light, 
phosphenes,  or  other  indications  of  irritation  of  the  retinal 
elements. 

Treatment  consists  in  the  relief  of  all  exciting  causes,  giving 
rest  to  the  eyes,  and  using  such  remedies  as  Bell.,  Phos., 
Dubois.,  Conium,  Bry.,  Puis.,  or  Verat.  vir. 

Anaemia  or  Isch^emia  of  the  Retina  results  from  obstruc- 
tion of  the  circulation  in  the  retinal  vessels,  as  will  be 
considered  under  embolism  and  thrombus  of  the  central  arterv. 


376  DISEASES  AND  INJURIES  OF  THE  EYE. 

It  also  occurs  in  cases  of  general  anaemia,  and  has  been 
observed  in  the  prostration  following  cholera  or  other  diseases. 
The  failure  in  the  retinal  circulation  occui's  suddenly  and 
there  is  immediate  loss  of  vision,  which  is  usually  temporary, 
the  sight  returning  after  a  few  hours  or  days. 

Treaiment. — If  the  vision  does  not  return  after  forty -eight 
hours  under  the  administration  of  China,  Ferrum,  Phos.,  or 
other  remedies  that  may  be  indicated,  together  with  the  use  of 
nourishing  food  and  stimulants,  a  paracentesis  of  the  cornea 
should  be  made  to  relieve  the  intra-ocular  tension  and  restore 
the  circulation. 

Embolism  or  Thrombosis  of  the  Central  Artery  of  the 
retina,  or  one  of  its  principal  branches,  gives  rise  to  sudden 
loss  of  vision,  which  may  be  complete  or  partial,  depending 
upon  the  position  and  size  of  the  embolus.  The  vision  may  be 
slightly  improved  by  the  establishment  of  collateral  circulation, 
but  it  is  not  usually  permanent,  and  the  retinal  function  is 
lost,  or  inflammatory  changes  occur,  characterized  by  cedema 
of  the  retina,  about  the  disc  or  yellow  spot,  which  gives  to  the 
choroid  a  misty  appearance,  while  in  the  fovea  a  red  spot  may 
appear  which  simulates  a  hemorrhage  at  this  point.  Later,  the 
redness  becomes  paler  and  the  retinal  vessels  affected,  when 
detected,  may  appear  as  a  whitish  cord  or  not  changed,  except 
from  the  absence  of  producible  pulsation.  In  a  few  weeks  the 
disc  appears  white  and  passes  into  a  state  of  atrophy.  These 
cases,  which  occur  very  rarely,  may  arise  in  connection  with 
diseases  of  the  heart,  and  according  to  some  authorities 
are,  in  the  majority  of  cases,  due  to  hemorrhages  in  ihe 
optic  nerve  sheath  which  present  the  same  ophthalmoscopic 
appearances. 

Treatment  is  unavailing,  as  the  sight  is  completely  lost,  yet 
such  remedies  as  Crotalus,  Lachesis  or  Prunus,  which  may 
cause  absorption  of  the  blood,  may  be  tried  when  the  diagnosis 
is  doubtful. 

Hemorrhages  into  the  Ketina. — Blood  effusions  into  the 
retina  occur  spontaneously  in  persons  of  a  hemorrhagic 
diathesis  or  those  suffering  from  menstrual  derangements ;  also 


DISEASES  OF  THE  RETINA— RETINITIS.  377 

from  degeneration  of  the  blood-vessels,  cardiac  disease,  and 
from  injuries  and  diseased  conditions  of  the  eye,  as  glaucoma, 
choroidal  diseases  in  myopic  eyes,  or  inflammation  of  the 
retina  itself. 

Symptoms  and  Diagnosis. — The  vision  is  affected  according 
to  the  location  and  extent  of  the  effused  blood  and  as  it 
approaches  or  covers  the  macula  lutea.  Hemorrhages  into  the 
retina  are  readily  recognized  by  means  of  the  opthalmoscope 
as  red  patches,  and  their  appearance  depends  upon  the  loca- 
tion and  depth  of  the  effusion.  If  they  occur  in  the  vicinity 
of  the  optic  disc,  they  are  generally  more  superficial  and 
present  a  somewhat  striated  and  irregular  form  as  they  spread 
through  the  ner\'e  fibre  layer  and  cover  the  retinal  vessels.  If 
the  patches  are  deeper  in  the  retinal  tissue,  they  are  smaller, 
the  edges  more  rounded  and  the  retinal  vessels  may  be  seen  to 
pass  uninterruptedly  over  them. 

Prognosis. — The  effusion  gradually  becomes  absorbed,  and 
if  very  small,  may  leave  no  trace;  more  often  pigment  spots 
or  deposits  of  white  fibrin  result,  indicating  inflammatory 
changes  at  the  point.  If  the  hemorrhage  is  extensive,  retinitis 
is  very  sure  to  occur  and  serious  secondary  changes  follow. 
If  the  hemorrhage  has  occurred  in  the  macula,  the  sicrht  is 
rarely  regained,  and  even  with  the  partial  restoration  of  the 
vision,  the  layer  of  cones  has  generally  sustained  such  displace- 
ment as  to  cause  distortion  and  irregularities  in  the  appear- 
ance of  objects. 

Hemorrhages  into  the  vitreous  are  often  an  indication  of 
the  diseases  mentioned  among  the  productive  causes,  and  may 
also  be  the  forerunner  of  cerebral  diseases  which  may  involve 
the  life  of  the  patient. 

Treatment. — The  eye  must  be  given  absolute  rest  and  pro- 
tected from  the  light,  and  such  remedies  administered  as  may 
hasten  absorption,  together  with  others  adapted  for  the  condi- 
tion which  may  be  the  exciting  cause.  Of  the  remedies  which 
may  hasten  the  absorption  of  the  effusion.  Bell.,  Lachesis  and 
Crotalus  are  to  be  used. 


378  DISEASES  AND  INJURIES  OF  THE  EYE. 

RETINITIS. 

Acute  retinitis,  uncomplicated  with  inflammation  of  the 
choroid,  optic  nerve  or  other  portions  of  the  eye,  is  very  rare. 
The  inflammatory  process  takes,  usually,  a  more  passive  char- 
acter and  the  morbid  changes  occur  more  slowly.  Of  the 
many  morbid  changes  which  may  occur  in  the  retina,  but  few 
of  them,  however,  take  origin  in,  or  are  confined  to,  the  retina 
itself.  Inflammation  of  the  retina  causes  certain  changes  in 
its  structure  which  lessen  its  transparency  by  infiltration  of 
its  tissue,  resulting  in  hypertrophy  of  its  connective  tissue 
structure  which  may  cause  considerable  increase  in  its  thick- 
ness and  render  it  opaque.  The  exudative  material  may  be 
serous,  plastic  or  purulent.  These  exudations  may  be  absorbed 
or  pass  into  a  state  of  sclerosis  or  fatty  degeneration,  and  the 
integrity  of  the  retina  will  suffer  according  to  the  extent  and 
length  of  time  the  exudation  remains. 

Causes. — Retinitis  more  commonly  follows  inflammation  of 
the  choroid,  yet  Ave  meet  with  uncomplicated  retinitis  which  is 
the  result  of  syphilis  or  some  other  constitutional  dyscrasia, 
and  in  patients  who  have  diseases  of  the  kidney,  diabetes, 
menstrual  disorders,  leucocythemia,  malaria,  etc.  When  asso- 
ciated udth  optic  neuritis,  brain  diseases  and  other  causes 
excite  it. 

SYMrxOMS. — There  are  no  external  appearances  of  disease  in 
the  eye,  nor  is  there  any  pain,  and  the  impairment  of  the 
vision  is  the  only  symptom  complained  of. 

The  ophthalmoscopic  evidences  (Plate  V,  Fig.  4)  consist  of 
loss  of  transparency  and  the  presence  of  opaque  portions  of 
the  retina.  The  opacities  vary  in  size  and  shape  in  the  differ- 
ent varieties  of  retinitis;  and  with  the  white  patches  are  seen 
more  or  less  hemorrhagic  spots.  The  varieties  of  retinitis 
have  been  designated,  according  to  their  ophthalmoscopic 
appearances  and  constitutional  causes,  into  retinitis  apoplec- 
tica,  retinitis  albuminurica,  retinitis  syphilitica,  retinitis  pig- 
mentosa, retinitis  proliferans  and  retinitis  leucremica. 

Retinitis  Apoplectica,  or  hemorrhagic  retinitis,  is  charac- 


PLATE  V 


Optic  Neuritis 

5 


Rebinitis     Album  inurica 
6 


Atrophy  oP   Optic  Nerve 
AFLerOptic  Neuritis 


Progressive    Optic 
Nerve  Atrophy. 


RETINITIS:  APOPLECTICA—ALBUMINURICA.  379 

terizecT  by  the  effusion  of  blood  into  the  retina  in  spots  of 
varying  size,  usually  small,  which  are  disseminated  over  a 
large  portion  of  the  retina  and  confined  to  one  eye  or  affecting 
both.  In  addition  to  the  effused  blood,  there  is  always  evi- 
dence of  inflammation  of  the  retina  and  optic  nerve.  Th& 
optic  disc  is  hyperaemic,  the  retinal  vessels  are  enlarged  and 
tortuous,  and  there  is  a  serous  effusion,  or  small  patches  of 
exudation  here  and  there  are  observed  in  the  retina. 

Causes.  —  Atheromatous  conditions  of  the  blood-vessels, 
diseases  of  the  heart,  as  hypertrophy  and  changes  in  the- 
aortic  valves,  together  with  a  syphilitic,  rheumatic  or  gouty 
diathesis  seem  to  furnish  the  causes  of  this  form  of  retinal 
disease.  The  retinitis  which  occurs  in  diabetes  frequently 
assumes  the  hemorrhagic  form. 

Symptoms.  — The  chief  subjective  symptom  is  more  or  lesa 
sudden  loss  of  vision;  the  objective  symptoms  consist  in  the 
exhibition  of  spots  of  effused  blood  in  the  retina,  which  are 
found  along  the  vessels,  and  the  hazy  condition  of  some 
portions  of  the  retina  from  infiltration,  or  the  appearance  of 
exudation. 

Prognosis.  —  The  prognosis  depends  somewhat  upon  the 
cause,  but  more  upon  the  extent  and  location  of  the  hemor- 
rhage. If  the  hemorrhages  are  marked  in  the  macula  lutea 
or  appear  in  the  fovea,  central  vision  is  almost  invariably 
destroyed,  while  if  they  affect  the  more  peripheral  portions  of 
the  retina  and  the  macula  is  unaffected,  and  the  hemorrhages 
are  promptly  absorbed,  the^result  may  not  be  very  serious  to 
vision.  As  a  rule,  however,  the  blood  is  absorbed  very  slowly 
and  months  pass  without  the  effusion  clearing  up.  If  the 
vision  is  seriously  affected  the  prognosis  is  usually  unfavor- 
able, as  entire  restoration  is  very  rare,  but  if  the  macula  has 
been  implicated  there  is  no  probability  of  the  return  of 
central  vision.  It  should  be  remembered  that  similar  effu- 
sions are  liable  to  occur  in  the  brain  from  the  same  causes, 
and  life  be  endangered. 

Treatment — Rest  from  all  mental  labor  and  cerebral  excite« 
ment  should  be  secured,  and  due  consideration  given  to  thd. 


^80  DISEASES  AND  INJURIES  OF  THE  EYE. 

•exciting  causes.  In  severe  cases,  when  the  hemorrhages  are 
increasing,  the  eye  should  be  bandaged  and  the  patient  con- 
fined to  bed.  In  milder  cases  the  patient  may  have  the  eyes 
protected  by  dark  glasses  and  be  allowed  moderate  exercise. 
Bell.,  Phos.,  Lachesis,  Crotalus  and  Merc,  cor.,  hasten  absorp- 
tion and  improve  the  condition  of  the  retina. 

Retinitis  Albuminueica,  or  nephritic  retinitis,  is  a  form  of 
retinal  inflammation  which  is  characterized  by  an  exudation  of 
albuminous  material  into  the  tissue  of  the  retina,  which  soon 
passes  into  fatty  or  fibrinous  degeneration,  affecting  both  the 
nerve  fibres  and  the  connective  tissue  of  the  retina.  Both 
eyes  are  almost  always  diseased. 

Causes. — Albuminuric  retinitis  is  perhaps  the  most  common 
form  of  inflammation  which  is  confined  to  the  retina,  and  is 
due  to  some  lesion  of  the  kidneys.  It  is  frequently  the  first 
intimation  of  Bright's  disease,  and  may  precede  all  evidence 
of  albumen  in  the  urine  for  some  weeks,  or  may  appear  only 
in  the  later  stages  of  the  disease.  It  occurs  in  about  eight  or 
nine  per  cent,  of  all  cases  of  Bright's  disease  and  usually  in 
the  chronic  form,  and  here  is  more  commonly  associated  "with 
<;ontracted  kidney.  The  albuminuria  of  pregnancy  or  scarlet 
fever  may  also  cause  the  disease.  Any  form  of  kidney  disease, 
as  waxy  or  fibrous  degeneration  or  white  hypertrophy,  which 
produces  an  urfemic  condition  of  the  blood,  is  sufficient  to 
excite  the  retinal  inflammation. 

Symptoms  and  Diagnosis. — The  failure  of  the  vision  is  the 
first  symptom  which  may  indicate  the  eye  affection.  The 
ophthalmoscopic  picture  is  a  very  striking  one  (Plate  Y,  Fig.  4). 
The  optic  disc  is  more  or  less  hyperaemic  and  swollen,  with 
indistinct  edges,  and  the  vessels  turgid,  or  again  the  disc  may 
appear  flat,  white,  and  the  vessels  but  little  changed.  In  the 
retina,  however,  at  some  distance  from  the  disc,  and  frequently 
in  the  region  of  the  macula,  are  obsers'ed  the  chief  features 
of  the  ophthalmoscopic  appearances;  these  consist  of  opaque 
white  spots  of  varying  size,  often  very  large  and  striated, 
which  are  due  to  fatty  degeneration  of  the  connective  tissue 
of    the  retina  or  sclerosis  of    the  layer  of    the   optic  nerve 


RETINITIS  ALBUMINURICA.  ;  381 

fibres.  Hemorrhages  are  common  and  vary  in  size.  The 
retinal  vessels  are  covered  by  the  white  patches,  or  hemor- 
rhages, in  a  portion  of  their  course  and  often  the  exudations 
are  observed  along  the  sides  of  the  vessels.  The  white 
patches  may  consist  of  white  dots  which  are  grouped  around 
the  region  of  the  macula,  showing  white  lines  which  radiate 
from  the  fovea  with  dots  between,  and  the  retinal  changes 
appear  confined  to  the  region  of  the  yellow  spot.  In  most, 
cases  the  patches  are  much  larger  and  coalesce,  forming  a. 
more  or  less  distinct  zone  around  the  disc,  with  another  zone, 
between  the  disc  and  exudation,  of  apparently  healtliy  retina. 

In  rare  cases  we  may  find  what  would  seem  to  be  the 
primary  stage  of  the  disease,  which  consists  of  a  delicata 
haziness  of  the  retina  as  if  from  serous  infiltration.  As  the 
cases  do  not  usually  present  themselves  until  the  disease  is 
more  advanced,  there  is  no  opportunity  offered  for  a  frequent, 
examination  of  the  eye  in  the  early  stages. 

Prognosis. — Cases  occurring  during  the  course  of  acute 
disease  of  the  kidney  usually  clear  up  and  leave  little  impair- 
ment of  the  vision  unless  the  macula  has  been  affected,  when 
there  is  a  prompt  recovery  from  the  kidney  lesion.  The 
course  of  retinitis  in  the  chronic  diseases  of  the  kidney,  varies 
with  the  condition  of  the  latter.  The  prognosis  is  very  grave 
as  the  vision  is  very  greatly  impaired,  although  total  blindness 
does  not  usually  occur,  but  as  the  eye  affection  keeps  pace 
with  that  of  the  kidney,  there  is  little  to  be  expected  from  the 
treatment. 

Treatment. — The  treatment  of  retinitis  is  essentially  that  of 
the  disease  upon  which  it  is  dependent.  Protection  glasses 
and  complete  rest  for  the  eyes,  with  such  bodily  exercise  as 
may  be  proper  for  the  general  condition,  are  necessary.  Inter- 
nally, those  remedies  which  are  applicable  to  the  cause  of  the 
disease  will  be  indicated.  Among  the  remedies  particularly 
suitable  to  the  condition  of  the  eye  in  Bright' s  disease,  Merc, 
cor.,  and  Gels,  are  the  only  ones  which  have  seemed  at  all 
beneficial.  In  retinitis  arising  during  the  course  of  preg- 
nancy, Gelsemium  and  Apis  have  been  useful.     In  a  case  of 


382 


DISEASES  AND  INJURIES  OF  THE  EYE. 


retinitis  associated  with  post-scarlatinal  dropsy,  a  cure  was 
effected  by  the  use  of  Apis. 

Ketinitis  Syphilitica  differs  from  the  two  forms  of 
retinitis  just  described,  in  that  the  retinal  changes  are  due  to 
infiltration  with  serum  and  fibrine,  and  of  lymph  corpuscles, 
with  resulting  hypertrophy  of  the  connective  tissue.  Hemor- 
rhages and  large  patches  of  sclerosis  or  fatty  degeneration  are 
commonly  absent,  and  there  is  a  greater  tendency  to  choroidal 
implication  than  with  the  other  varieties. 

Causes. — The  disease  appears  usually  among  the  later 
secondary  symptoms  of  syphilis,  and  also  among  the  tertiary 
symptoms  of  inherited  syphilis.  In  women  it  may  appear 
among  the  first  symptoms  of  acquired  syphilis,  the  primary 
sore  and  the  light  secondary  symptoms  having  been  unobserved. 

Symptoms  and  Diagnosis. — The  sight  is  often  greatly 
impaired  when  but  slight  changes  are  observable  in  the  retina, 
and,  on  the  other  hand,  the  vision  may  be  but  slightly 
disturbed  when  the  retinal  lesion  is  very  great. 

The  retina,  particularly  at  the  centre  of  the  fundus,  or 
along  the  vessels,  appears  hazy,  and  yellow  spots  of  exudation 
are  discernible ;  these  are  often  very  minute  and  granular  and 
more  frequently  appear  about  the  macula  lutea,  where  the 
disease  shows  a  tendency  to  locate.  Patients  not  infrequently 
complain  of  phosphenes,  flashes  of  light,  scotoma,  and  changes 
in  the  appearance  and  size  of  objects,  from  the  disturbances  of 
the  relation  of  the  cones  at  the  yellow  spot.  One  eye  or  both 
may  be  affected  and  the  vitreous  may  become  hazy. 

Prognosis. — The  disease  may  last  from  three  to  eight  weeks 
or  as  many  months  and  shows  a  great  tendency  to  recurrence. 
Many  cases  recover  without  serious  impairment  of  sight,  if 
there  is  no  implication  of  the  choroid  and  the  general  condi- 
tion is  fair.  When  the  macula  is  the  seat  of  the  lesion,  the 
prognosis  becomes  grave,  as  the  vision  is  always  impaired  and 
in  many  cases  destroyed.  Atrophy  of  both  the  retina  and 
optic  nerve  may  follow  the  retinitis,  or  the  latter  may  be  the 
forerunner  of  brain  disease. 

Treatment. — The  treatment  is  to  be  directed  to  the  constitu- 


RETINITIS  PIGMENTOSA— SYMPTOMS.  383 

tional  causes,  and  of  the  remedies  which  are  likely  to  be 
further  indicated  for  the  general  condition  by  the  eye  lesions, 
Kali  iod.,  Merc.  cor.  and  Aurum  may  be  mentioned. 

Retinitis  Pigmentosa  is  a  chronic  form  of  progressive 
inflammation  which  manifests  itself  by  proliferation  of  the 
connective  tissue  of  the  retina  and  its  pigment  epithelium 
■with  consequent  atrophy  of  the  nerve  elements.  The  condi- 
tion appears  to  be  one  of  atrophy  of  the  whole  tissue  of  the 
retina  with  proliferation  of  the  pigment.  Its  pathology  is 
still  in  doubt,  but  it  is  probably  more  a  degenerative  condition 
which  may  be  preceded  by  slight  inflammatory  symptoms. 

Causes. — The  causes  are  unknown,  but  the  malady  is 
usually  hereditary,  at  least  more  than  one  member  of  a  family 
are  commonly  affected. 

Symptoms. — The  disease  is  usually  discovered  in  conse- 
quence of  the  patient's  complaining  that  vision  is  defective 
except  in  very  bright  light,  and  that  late  in  the  day,  or  during 
twilight,  or  after  dark,  vision  is  very  poor  or  impossible. 
This  condition  of  the  vision,  hemeralopia,  or  night  blindness, 
arises  because  the  retina  requires  the  full  stimulus  of  daylight 
to  enable  it  to  act.  In  addition  to  this,  the  field  of  vision  is 
contracted,  and  as  the  disease  advances  lessens,  until  at  last 
central  vision  disappears  and  complete  blindness  follows. 
The  ophthalmoscopic  appearances  in  the  early  stages  of  the 
disease  are  very  characteristic;  toward  the  equator  of  the 
fundus  numerous  irregular  mossy-like  patches  of  pigment 
with  star-shaped  projections  are  seen,  particularly  along  the 
line  of  the  blood-vessels.  The  vessels  are  lessened  in  calibre 
and  straighter;  as  the  disease  advances  these  pigmentary 
changes  become  more  numerous  and  approach  the  disc,  which 
becomes  whiter,  the  blood-vessels  are  attenuated,  the  retina 
hazy,  and,  as  the  disease  involves  the  macula,  the  vision 
disappears  entirely. 

Prognosis  is  unfavorable,  as,  in  the  present  state  of  our 
knowledge  of  therapeutics,  the  disease  results  in  complete 
blindness.  The  time  necessary  for  the  completion  of  the 
atrophic  process  is  often  many  years,  as  it  advances  slowly. 


384  DISEASES  AND  INJURIES  OF  THE  EYE. 

Treatment — As  yet  nothing  has  been  found  which  seems  to 
have  any  effect  upon  the  disease  beyond  those  measures  which 
are  instituted  to  improve  the  general  condition  of  the  patient, 
and  such  care  of  the  eyes  as  may  retain  the  sight  as  long  as 
possible.  Temporary  benefit  sometimes  results  from  the  use 
of  Lycop.  and  Phosph. 

Eetinitis  Proliferans  is  a  rare  form  of  retinal  inflam- 
mation, which  is  characterized  by  the  development  of 
connective  tissue  in  the  vitreous, 

Retinitis  Leuc^mica  is  also  a  very  rare  variety  of  retinitis 
which  occurs  in  some  cases  of  leucocythsemia.  The  fundus  of 
the  eye  presents  a  yellow  aspect,  with  white  patches  of  lymph 
corpuscles  and  hemorrhagic  spots  scattered  over  the  retina. 

Detachment  of  the  Eetina. — Separation  of  the  retina  by 

effusion  of  blood  or  serum  between  it  and  the  choroid,  may 

take  place  in  different  portions  of  the  ftlndua 

and  may  be  partial  or  complete.       If  the 

effusion  takes  place  in  the  upper  portion, 

the  fluid  gravitates  to  the  bottom,  as  in  Fig. 

148,  detaching  the  retina  as  it  works  down, 

while  the  upper  portion  may  again  become 

FIG.  148.  adherent.     Hence  the  displacement  of  the 

retina  is  more  frequently  observed  in  the  lower  part  of  the 

fundus. 

Causes. — The  most  frequent  cause  of  retinal  detachment  is 
myopia,  pai-ticularly  of  a  high  degree  and  when  associated 
with  choroidal  diseases  and  fluidity  of  the  vitreous.  It  occiu's, 
however,  in  emmetropic  eyes  as  the  result  of  severe  injuries  to 
the  eye,  of  iritis,  choroiditis,  and  neuro-retinitis  with  vitreous- 
changes,  or  in  derangements  of  the  nerves  with  lessened  pres- 
sure in  the  vitreous,  as  indicated  in  diminished  eyeball  tension 
after  injuries  that  have  induced  inflammation,  with  subsequent 
fluidity  of  the  vitreous.  The  detachment  may  be  complete, 
the  retina  having  a  funnel  shape  with  the  apex  at  the  optic 
disc. 

Symptoms. — Detachment  of  the  retina  causes  a  defect  in  the 
field  of  vision  corresponding  to  the  location  of  the  separation;. 


DETACHMENT  OF  THE  RETINA.  385 

if  the  detachment  occurs  in  the  lower  portion  of  the  retina,  the 
patient  is  unable  to  see  anything  above  a  certain  line.  The 
disturbance  of  vision  varies  with  the  amount  and  location  of 
the  detachment;  if  the  retina  is  detached  at  or  near  the  macula, 
the  impairment  is  much  greater,  than  if  a  more  extensive  sepa- 
ration exists  at  its  periphery.  The  patient  may  first  notice 
that  the  vision  is  clouded,  and  objects  appear  wavy  or  distorted, 
and  fringed  with  prismatic  colors.  Again,  colored  or  white 
bodies  appear  before  the  eye  or  flashes  of  light  arise  from  the 
irritation  of  the  retinal  elements.  With 
the  ophthalmoscope  detachment  is  easily 
diagnosed,  as  the  separated  retina  presents 
a  bluish-gray,  floating,  tremulous,  wave- 
like opacity  which  is  thrown  into  folds, 
or  has  an  undulating  appearance  on  any 
motion  of  the  eye,  as  in  Fig.  149.  If  the 
no.  149.  retinal  vessels  are  traced  from  the  disc  to 

the  detached  portions,  they  will  be  seen  to  end  abruptly  or 
bend  backward,  or  as  they  pass  over  the  projecting  retina  they 
are  nearer  to  our  eye  and  require  a  change  of  focus  from  that 
necessary  to  observe  the  vessels  on  the  other  portions  of  the 
retina.  When  the  detachment  is  complete  the  vision  is  com- 
pletely destroyed,  and  the  retina  appears  as  an  opaque  bluish 
mass  behind  the  lens,  if  the  latter  is  not  already  cataractous. 

Prognosis.— In  rare  cases  absorption  of  the  fluid  with  re-at- 
tachment of  the  membrane  and  restoration  of  the  vision  takes 
place.  As  a  rule  these  cases  of  detachment  present  an  unfa- 
vorable prognosis.  Some  cases  may  remain  stationary,  but 
more  frequently  the  effusion  increases  until  the  separation 
becomes  extensive  or  complete  and  the  vision  destroyed. 

Trecdment — The  operation  of  puncturing  the  retina  by  the 
introduction  of  a  cataract  needle  through  the  sclerotic  has,  in 
the  hands  of  some  operators,  proved  beneficial,  but  the  opera- 
tion has  not  been  sufficiently  successful  to  make  the  procedure 
of  any  value.  The  best  method  of  treatment,  if  the  detach- 
ment is  recent,  is  to  confine  the  patient  to  bed,  bandage  the 
eyes,  and  administer  such  remedies  as  may  induce  absorption^ 
25 


886  DISfJASES  AND  INJURIES  OF  THE  EYE. 

If  the  detachment  is  old,  the  eyes  ehould  be  protected  from 
the  irritation  of  light  by  dark  glasses  and  all  use  of  the  eyes 
avoided.  Occasionally  the  local  use  of  atropine  is  advanta- 
geous, the  rest  for  the  ciliary  body  which  results  from  its  use 
preventing  further  detachment  The  most  brilliant  results 
have  followed  the  administration  of  our  homoeopathic  remedies 
in  some  of  these  cases,  particularly  Gelsemium,  Arnica  and 
Aurum.  Benefit  has  also  been  derived  from  Apis,  Merc,  and 
Digitalis.  Other  remedies  will  undoubtedly  bo  found  valuable 
in  the  treatment  of  detachment  as  opportunities  for  the  clin- 
ical application  of  our  remedies  to  the  condition  increase. 

FUNCTIONAL  DISEASES  OF  THE  RETINA. 

Hyperesthesia  Retinae  or  extreme  sensitiveness  of  the 
retina  may  be  a  symptom  of  inflammation  of  that  tissue,  but  is 
also  the  result  of  close  application  of  the  eyes  in  fine  work  on 
bright  or  glistening  objects,  as  in  two  cases  which  have  come 
under  my  notice  where  the  condition  resulted  from  prolonged 
efforts  with  the  microscope  in  the  one  case,  and  the  other 
occurred  in  a  metal  turner  who  worked  on  brass  disks  in  a 
bright  light  In  these  cases  there  were  no  changes  in  the 
retina  beyond  a  possible  hypersemic  condition.  It  is  more 
frequently  met  with  in  hysterical  or  hypochondriacal  people 
who  generally  present  some  refractive  trouble,  associated  with 
accommodative  or  muscular  asthenopia,  and  usually  follows  an 
attack  of  illness.  Two  cases  I  have  seen  follow  the  puerperal 
condition. 

Symptoms. — There  is  great  sensitiveness  to  light,  and  often 
complete  inability  to  use  the  eyes.  Exposure  to  light,  or 
attempted  use,  brings  on  lachrymation,  pain  and  blepharospasm. 
Milder  cases  may  complain  only  of  dazzling,  or  the  retinal 
impressions  may  persist  for  a  longer  time  than  usual  and 
interfere  with  the  rapid  inspection  of  objects,  or  remain  after 
the  eyes  are  closed.  These  patients  in  severe  cases  confine 
themselves  to  close  rooms  from  which  every  ray  of  light  is 
excluded  or  even  then  keep  the  eyes  bandaged. 


t 
SNOW  BLINDNESS— NYCTALOPIA— HEMERALOPIA.  387 

Prognosis. — The  prognosis  is  favorable,  as  the  proper  treat- 
ment is  prompt  in  relieving  the  condition,  and  the  dread  of 
blindness,  which  is  the  reactive  cause,  may  be  relieved  by- 
encouraging  assurances,  after  a  complete  examination  has  been 
made. 

Treatment. — An  examination  of  the  eyes  should  be  made 
even  if  it  is  necessary  to  administer  an  anaesthetic,  when  any 
refractive  errors  must  be  determined  by  the  ophthalmoscope, 
and  in  the  absence  of  any  retinal  changes  which  may  be  pro- 
ductive of  the  condition,  the  patient  should  be  assured  of  a 
full  recovery.  This  encouragement  itself  is  productive  of  the 
greatest  good,  as  these  cases  commonly  appear  in  nervo-hyster- 
ical  subjects. 

Locally  atropine  may  be  useful,  and  the  patients  should  be 
admonished  not  to  exclude  the  light  but  gradually  accustom 
the  eyes  to  it,  and  this  will  aid  materially  in  relieving  the 
fears  of  the  patient.  Any  error  of  refraction  should  be 
Corrected  as  soon  as  possible,  and  the  general  condition  of  the 
patient  improved  by  proper  hygienic  measures.  The  proper 
homoeopathic  remedy  is  invaluable  in  the  treatment  of  these 
cases  and  the  results  of  its  administration  are  wonderful  at 
times.  Of  these  remedies  Bell.,  Conium,  Ignatia,  Macrotin, 
Nux  Vomica  and  Natrum  mur.  are  particularly  serviceable, 
while  Acnoite,  China,  Hyos.,  Lactic  acid  and  Merc.  sol.  may 
be  indicated  more  rarely. 

Snow  Blindness  is  an  affection  resulting  from  prolonged 
exposure  to  the  bright  reflection  of  the  light  from  areas  of 
snow  and  during  winters  which  are  accompanied  by  great 
snow  falls  which  remain  for  weeks  or  months.  These  cases 
are  frequently  met  with  in  our  northwestern  states.  There  is 
often  extreme  irritability  of  the  eyes  with  conjunctival  hyper- 
semia,  pain  and  extreme  photophobia.  The  immediate  symp- 
toms may  pass  off  in  a  few  hours  or  days,  but  in  the  cases 
which  usually  come  to  the  city  for  treatment  there  is  a  marked 
hypersesthesia  of  the  retina,  which  may  persist  for  weeks  or 
months  afterwards.  The  treatment  is  the  same  as  that  already 
given  for  hyperaesthesia  of  the  retina. 


388  DISEASES  AND  INJURIES  OF  THE  EYE. 

Nyctalopia  or  day  blindness  is  sometimes  applied  to 
certain  cases  of  hypersesthesia  retinae  where  the  patients  are 
able  to  use  the  eyes  in  dimly-lighted  rooms  or  at  night,  and 
yet  are  unable  to  do  any  work  during  day-time,  or  see  when 
the  eyes  are  exposed  to  bright  sunlight. 

Anesthesia  Eetin.e,  or  torpor  of  the  retina,  is  a  condition 
opposite  to  that  just  described  in  which  vision  is  only  possible 
in  bright  light.  From  observation  and  experiments  which  I 
have  made  in  the  provings  of  certain  remedies,  it  seems  to  me 
to  be  dependent  upon  the  defective  innervation  which  lessens 
the  rapidity  of  the  secretions  of  the  visual  purple,  inasmuch 
as  the  condition  is  rapidly  improved  by  the  internal  adminis- 
tration of  low  attenuations  of  Jaborandi  and  Agaricus  and  the 
higher  attenuations  of  Lycopodium  and  Hepar  s.  Among 
the  causes  which  may  be  mentioned  is  exposure  to  bright 
lights,  especially  in  anaemic  patients.  It  is  also  not  ulicom- 
mon  in  sailors  who  are  exposed  to  the  bright  sun  of  the 
tropics  in  long  voyages  when  the  night  is  bright  as  well  as 
the  day.  There  are  certain  cases,  as  those  occurring  in 
squint  from  non-use  of  the  eyes,  or  concussion  of  the  eye,  or 
in  senile  degeneration  of  the  retina,  as  well  as  those 
depending  upon  atrophic  conditions  of  the  optic  ners^e  and 
retina,  which  are  not  benefited  by  remedial  treatment. 

Hemeralopia,  or  night  blindness,  is  a  term  which  is  often 
applied  to  those  cases  occurring  where  the  vision  is  better 
during  the  day-time  than  by  dim  or  artificial  light.  In  cases 
presenting  these  symptoms  we  should  closely  examine  the 
retina  for  some  indication  of  retinitis  pigmentosa,  of  which  it 
is  a  common  symptom. 

Commotio  Retina  is  a  term  applied  to  sudden  loss  of 
vision  occurring  from  concussion  of  the  eyeball,  after  blows 
received  upon  the  eyeball,  or  upon  neighboring  parts  and  also 
after  a  stroke  of  lightning.  There  are  usually  no  ophthal- 
moscopic changes  apparent,  yet  the  blindness  is  often  complete 
and  permanent. 

Hemiopia  is  loss  of  function  of  the  lateral  half  of  the 
retina,  and  usually  affects  the  same  side  in  both  eyes.     In  this 


HEMIOPIA— SCOTOMA.  889 

condition  there  is  loss  of  sight  of  the  affected  portion.  Com- 
monly there  is  absence  of  the  right  or  left  half  of  the  object, 
as  when  the  right  or  left  sides  of  each  retina  are  affected, 
when  the  condition  has  been  termed  homonymous  hemiopia; 
if  both  the  internal  or  external  sides  of  the  retina  are  blind 
the  hemiopia  is  termed  respectively  temporal  or  nasal.  In 
very  rare  cases  the  upper  or  lower  half  of  the  field  may  be 
wanting.  These  cases  are  due  to  causes  which  lie  in  the 
brain  or  in  the  optic  tracts  behind  the  commissure.  Some- 
times these  affections  are  temporary,  and  due  to  some  disturb- 
ances of  the  circulation.  They  are,  however,  commonly 
permanent,  and  associated  with  intra-cranial,  syphilitic,  tuber- 
cular or  other  diseased  conditions  of  the  brain,  such  as  tumors. 
As  a  rule  there  is  no  change  in  the  ophthalmoscopic  appear- 
ances of  the  retina  beyond  a  possible  contraction  of  the  arte- 
ries and  hypersemia  of  the  disc. 

Treatment — The  treatment  must  be  directed  to  the  discern- 
ible or  probable  cause.  Certain  of  our  remedies  are  useful  in 
some  of  the  cases  and  others,  from  their  provings,  give 
promise  of  value.  When  the  upper  half  of  the  field  of  vision 
is  defective,  Aurum,  Dig.,  and  Gels,  should  be  remembered, 
while  for  homonymous  hemiopia,  Calc.  carb.,  Morph.  sulph., 
Muriatic  acid,  Plumb.,  Sepia  and  Stramonium,  and  when  the 
right  half  of  the  object  is  wanting  Lith.  carb.  and  Lycop.  are 
to  be  considered. 

Scotoma  is  a  term  which  is  applied  to  other  less  extensive 
disturbances  of  the  fundus  of  the  retina;  when  only  a  small 
portion  of  the  retina  is  insensible  to  light,  this  portion 
appears  to  the  patient  as  a  black  spot  in  the  field  of  vision, 
and  is  then  termed  a  positive  scotoma;  when  it  is  only  found 
by  an  examination  of  the  visual  field  and  not  apparent  to  the 
patient,  it  is  termed  a  negative  scotoma;  of  the  latter  the 
absence  of  that  portion  of  the  field  which  corresponds  to  the 
optic  disc  is  apparent  in  the  normal  visual  field;  if  the  macula 
is  affected  a  central  scotoma  is  present.  Scotoma  commonly 
occurs  in  diseases  of  the  optic  nerve. 

Causes. — Scotoma    may  appear  as   the  result  of   injuries. 


390  DISEASES  AND  INJURIES  OF  THE  EYE. 

diseases  of  tlie  retina  or  heraorrliages,  opacities  of  the  vitreous, 
or  diseases  of  the  optic  nerve  or  of  the  brain.  It  may  also 
occur  from  exposure  of  the  eye  to  bright  sunlight,  as  in 
observing  an  eclipse  of  the  sun  through  a  telescope,  or  from 
exposure  to  a  very  brilliant  flash  of  lightning.  In  many 
cases,  however,  there  is  purely  functional  loss  without 
apparent  tissue  change. 

Treatment — No  special  treatment  of  the  eye  is  advisable  in 
these  cases  beyond  that  indicated  for  the  condition  upon 
which  the  scotoma  depends. 

Color  Blindness  is  an  impairment  of  the  function  of  the 
retina  with  inability  to  discriminate  colors,  and  is  usually 
congenital;  but  it  is  also  met  with  in  an  acquired  form,  in 
many  diseases  which  affect  the  retina,  optic  nerve,  brain  or 
spinal  cord.  In  the  congenital  form,  which  Avill  be  considered 
here,  the  patient's  sight  may  in  every  respect  be  perfect,  but 
he  is  unable  to  distinguish  certain  colors,  as  red,  green  or 
blue  when  there  is  partial  color  blindness,  or  there  may  be 
absolute  color  blindness,  black  and  white  alone  being  recog- 
nized. The  most  common  form  of  color  blindness  is  the 
partial,  and  occurs  in  about  four  per  cent,  of  males  to  one  per 
cent,  of  females,  and  is  more  frequent  in  the  lower  classes. 
Color  blindness  for  red  is  the  form  most  frequently  presented. 
The  faulty  perception  of  the  various  shades  of  green  are  next 
in  frequency,  while  the  perception  for  blue  or  yellow  is  very 
rarely  absent.  The  cause  and  pathology  of  color  blindness  is 
as  yet  unknown.  The  detection  of  color  blindness  is  of  the 
utmost  importance  and  should  be  thoroughly  understood,  and 
of  the  numerous  tests  proposed,  that  of  Holmgren,  described 
in  Chapter  II,  will  afford  the  most  satisfactory  results. 

The  condition  is  not  amenable  to  treatment  except  in  the 
acquired  form,  which  will  be  considered  in  speaking  of 
diseases  of  the  optic  nerve. 

'  TUMORS  OF   THE  RETINA. 

Glioma  of  the  retina,  which  has  its  origin  in  the  granular 
layers  or  arises  from  the  connective  tissue  of  the  retina,  is  the 


TUMORS  OF  THE  RETINA— DIAGNOSIS. 


391 


only  kind  of  tumor  occurring  in  this  tissue.  It  consists  of 
round  cells  and  nuclei,  imbedded  in  a  small  quantity  of  inter- 
cellular substance,  and  there  is  frequently  a  marked  develop- 
ment of  blood-vessels.  As  the  growth  increases  and  involves 
other  portions  of  the  eye,  it  partakes  of  the  characteristics  of 
sarcoma.  It  more  commonly  appears  in  one  eye,  but  not 
infrequently  affects  both. 

Causes. — Glioma  arises  almost  exclusively  in  very  young 
people,  between  the  ages  of  one  to  twelve  years,  though  it  may 
appear  as  early  as  one  month  after  birth,  and  would  seem  to 
be  hereditary  and  dependent  upon  cancerous  dyscrasia  in  the 
family.  In  extremely  rare  cases  it  may  develop  in  older 
persons,  when  it  first  appears  as  a  white  patch  in  the  retina. 
In  general  the  causes  are  obscure. 

Sympioms  and  Diagnosis. — The  earliest  symptom  is  a 
whitish,  yellow,  or  bluish-white  appearance  of  the  pupil,  which 
on  examination  is  found  to  exist  |3ehind  the  lens,  and  the  eye 
is  devoid  of  vision.  No  pain  or  redness  is  present,  and  often 
the  case  is  not  brought  for  treatment  until  the  eye  becomes 
enlarged,  or  pain  and  congestion  of  the  sclera  occur.  As  the 
tumor  grows  it  advances  into  the  interior  of  the  eyeball, 
producing  atrophy  and  detachment  of  the  retina  as  it  proceeds. 
With  the  ophthalmoscope,  it  appears  like  detachment  of  the 
retina  or  inflammatory  changes  in  the  vitreous,  which  closely 
simulate  it,  and  from  which  it  must  be  distinguished  by  the 
absence  of  iritic  adhesions,  and  from  the  history  of  the  inflam- 
mation preceding  the  white  or  yellowish  appearance  of  the 
pupil.  The  appearance  of  vessels  upon  the  surface  of  the 
bulging  mass,  which  do  not  correspond  with  those  of  the 
retina,  will  enable  us  to  designate  it  from  other  affections.  As 
the  tumor  increases  in  size  the  intra-ocular  tension  increases, 
and  the  pupil  becomes  dilated  and  the  child  complains  of  pain 
from  the  glaucomatous  condition  which  occurs.  Other 
portions  of  the  tissues  of  the  globe  become  involved  with  the 
increase  of  the  tumor,  and  the  lens  loses  its  transparency,  the 
cornea  becomes  opaque,  and  all  semblance  of  the  eyeball  is 
lost  in  the  protruding  mass  which  extrudes  between  the  lids, 


392  DISEASES  AND  INJURIES  OF  THE  EYE. 

and  appears  as  a  fleshy  body,  secreting  a  sanious  discharge 
and  subject  to  frequent  hemorrhages  in  the  advanced  stage  of 
the  disease,  when  it  is  called  fungus  hcematodes  of  the  eye. 

Prognosis. — When  the  disease  is  recognized  in  the  early 
stages,  while  confined  to  the  retina,  the  removal  of  the  eyeball 
with  a  portion  of  the  optic  nerve,  which  on  examination  shows 
no  sign  of  implication,  is  usually  favorable.  The  case,  how- 
ever, is  even  then  not  safe  until  several  months  or  a  year  have 
passed  without  indications  of  the  return  of  the  growth.  In 
the  majority  of  cases  the  removal  of  the  eye  is  not  acceded  to, 
or  the  disease  has  progressed  along  the  optic  nerve  so  that  the 
brain  is  oftentimes  affected,  or  the  contents  of  the  orbit  have 
become  infiltrated  with  cancerous  cells,  so  that  death  follows 
at  an  early  date,  from  intra-cranial  tumor  or  exhaustion  due  to 
the  cancerous  cachexia. 

Treatment. — Immediate  removal  of  the  ball  with  as  great  a 
portion  of  the  optic  nerve  as  possible,  is  imperative  when  the 
tumor  is  confined  to  the  interior  of  the  eye.  When  it  has 
extended  beyond  the  confines  of  the  globe  the  question  of 
operative  interference  is  a  grave  one,  as  often  the  complete 
extirpation  of  the  contents  of  the  orbit  affords  only  temporary 
relief,  the  sarcomatous  mass,  under  these  circumstances, 
seeming  to  acquire  fresh  energy  from  the  operative  measures. 

In  extremely  rare  cases  the  growth  is  reported  to  have  been 
checked  and  the  eyeball  become  atrophied,  but  this  is  so 
unusual,  and  the  general  tendency  of  the  disease  so  fatal,  that 
time  should  not  be  lost  in  awaiting  probable  absorption. 
After  the  removal  of  the  growth,  it  is  my  practice  to  place 
these  patients  upon  carbolic  acid  Ix  in  water,  three  times 
a  day  for  several  months,  and  good  results  have  occurred 
from  its  use. 


CHAPTEE     XXL  ' 

DISEASES  OF  THE  OPTIC  NEKVE. 
ANATO:\IY. 

The  optic  nerve  connects  the  retina,  its  ultimate  expansion 
for  the  reception  of  visual  impressions,  with  the  brain  centres 
where  perception  takes  place.  It  may  be  divided  for  examina- 
tion into  three  parts,  the  cranial,  orbital  and  ocular  portions. 

The  ultimate  origin  of  the  optic  nerve  has  been  determined 
to  be  in  the  grey  matter  near  the  gyrus  angularis  of  the  occi- 
pital lobes.  Other  points  of  origin  have  been  found  in  the 
optic  thalami,  corpora  quadrigemina,  posterior  columns  of  the 
spinal  cord,  corpora  geniculata,  cms  cerebri,  tuber  cinerum, 
the  lamina  cinera,  and  the  anterior  perforated  space.  The 
filaments  connecting  these  portions  of  the  brain  and  spinal 
cord  are  brought  together  to  form  the  optic  tracts,  one  on  each 
side,  which  pass  forward  beneath  the  thalami  and  curve 
around  the  crus  cerebri,  to  unite  upon  the  olivary  process  of 
the  sphenoid  bone  to  form  the  optic  chiasm  or  commissure. 

At  the  commissure  a  partial  decussation  of  the  fibres  takes 
place,  the  outer  fibres  from  the  right  optic  tract  passing  direct 
to  supply  the  right  half  of  the  retina  of  the  right  eye,  the 
medial  fibres  passing  to  the  more  central  portions  of  the  retina 
while  the  inner  portion  goes  to  supply  the  inner  half  of  the 
retina  of  the  left  eye.     The  fibres  of  the  left  tract  are  also 

393 


394 


DISEASES  AND  INJUBIES  OF  THE  EYE. 


divided,  the  inner  portion  going  to  the  inner  half  of  the  right 
eye,  the  medial  fibres  to  central  portions  of  the  retina  of  tlie 
left  eye  and  the  outer  portion  passing  direct  to  the  outer 
portion  of  the  retina  of  the  left  eye.  At  the  commissure, 
fibres  have  also  been  described  as  connecting  the  two  retinas 
and  have  been  termed  inter-retinal  fibres;  some  intra-cranial 
fibres  which  pass  directly  from  one  side  of  the  brain  through 
the  commissure  to  the  other,  without  going  to  the  eye,  have 
also  been  found. 

The  orbital  portion  of  the  optic  nerve  leaves  the  chiasm  and 
enters  the  foramen  opticum,  becoming  rounded  and  firmer  and 

consists  of  several  hun- 
dred bundles  of  nerve 
fibres  which  are  sep- 
arated from  each  other 
by  connective  tissue. 
After  passing  through 
the  foramen  it  emerges 
into  the  orbit  where  it 
curves  slightly  and 
passing  forward  enters 
the  eyeball  a  little  to 
the  nasal  side  and 
slightly  below  its  hori- 
zontal plane,  and  passes 
^^  through  the  sieve-like 
membrane,  the  lamina 
cribrosa  (Z  Fig.  150) 
in  the  opening  in  the 
sclera,  to  be  distributed 
to  the  various  portions 
of  the  retina.  The  orbital  portion  of  the  nerve  possesses  two 
sheaths,  an  external  one  (e)  the  prolongation  of  the  dura 
mater,  and  an  internal  one  [i]  formed  by  a  continuation  of 
the  pia  mater;  the  space  (v)  between  these  sheaths  which 
also  contains  a  prolongation  of  the  arachnoid,  forms  the  inter- 
vaginal    or    sub-dural    space    which    communicates    directly 


FIG.  150. 


ANATOMY  OF  THE  OPTIC  NERVE.  395 

with  the  cranial  cavity.  In  this  portion  of  the  nerve,  for 
a  distance  of  15  to  25  mm.  behind  the  eyeball,  a  central 
canal  (c)  is  formed  for  the  transmission  of  the  central  artery 
and  vein. 

The  ocular  portion  of  the  nerve  consists  of  that  portion 
which  enters  the  eyeball;  the  sheaths  which  have  covered  the 
orbital  portion  pass  over  and  are  continuous  with  the  sclera, 
while  the  inter-vaginal  space  ends  at  this  point,  and  the  optie 
nerve  fibres  leave  their  medullary  envelopes  and  pass  through 
the  lamina  cribrosa,  to  emerge  upon  the  interior  of  the  eye, 
where  they  form  a  slight  elevation  circular  in  form  and  about 
1.5  mm.  in  diameter,  the  optic  disc  or  papilla.  From  the 
edge  of  the  disc  the  nerve  fibres  curve  gently  to  pass  over  into, 
the  retina  to  form  its  nerve-fibre  layer. 

The  optic  disc  Avhen  examined  by  the  ophthalmoscope 
presents  a  pinkish  appearance  which  is  generally  deeper  in 
color  on  the  nasal  side.  The  color  is  due  to  the  blood  in  the 
capillaries,  and  as  these  blood-vessels  diminish  in  number,  as 
in  atrophic  conditions  of  the  nerve,  the  disc  becomes  white. 
At  the  margin  of  the  disc  a  black  circle  is  distinguished,  the 
choroidal  ring  (P  Fig.  150).  This  ring  may  be  entirely 
absent  or  appear  as  a  crescent.  Within  this  circle  is  discov- 
ered the  scleral  ring  (T  Fig.  150),  white  in  color,  and. 
marking  the  limit  of  the  pial  sheath.  In  the  centre  of  the 
disc  where  the  central  artery  enters,  a  small  funnel-like  depres- 
sion the  porus  opticus  (c  Fig.  150)  is  seen.  "When  the  nerve 
fibres  begin  to  branch  out  into  the  retina  at  the  lamina 
cribrosa  and  before  reaching  the  surface  of  the  papilla  a  more 
or  less  large  hollow  is  observed  in  the  disc;  this  constitutes 
the  physiological  cup.  When  this  excavation  is  large  it  may 
be  difficult  to  distinguish  it  from  the  cupping  which  occurs  in 
glaucoma;  it,  however,  never  extends  quite  up  to  the  scleral 
ring  and  does  not  present  the  displacement  of  the  blood- 
vessels which  are  common  to  the  pressure  excavation.  In 
these  cases  of  cupping  the  translucent  nerve  fibres  permit  the 
lamina  cribrosa  to  be  seen  and  give  to  the  optic  disc  a  mottled 
appearance. 


396  DISEASES  AND  INJURIES  OF  THE  EYE. 

DISEASES   OF   THE   OPTIC   NERVK 

Any  portion  of  the  optic  nerve,  either  in  the  cranium,  in 
the  orbit,  or  at  its  intra-ocular  distribution  may  become 
diseased.  The  changes  which  occur  may  begin  in  the  nerve 
itself,  or  extend  from  the  other  structures  of  the  eyeball,  from 
the  orbital  tissues,  or  from  diseases  of  the  brain,  or  more 
remote  organs  as  those  of  the  heart  or  kidney. 

The  pathological  changes  which  follow  are  similar  to  those 
W'hich  occur  in  diseases  of  the  retina  or  other  nerve  tissues. 
"We  may  have  hypercemia,  inflammation^  or  atrophy,  of  the 
■optic  nerve  fibres.  In  the  greater  number  of  instances,  the 
Tetina  participates  in  the  changes  and  the  condition  is  one  of 
neuro-retinal  disease. 

Any  lesion  of  the  nerve  may  lead  to  changes  in  its  struc- 
ture which  prevent  the  transmission  of  visual  impressions  to 
the  sensorium. 

HYPERiEMiA, — Capillary  congestion  of  the  optic  papilla  is 
the  common  accompaniment  of  hyperaemic  conditions  of  other 
portions  of  the  interior  structures  of  the  eye.  It  may  be 
indicative  of  cerebral  congestion,  inflammation  or  other 
morbid  processes  of  the  base  of  the  brain.  It  is  also  sympto- 
matic of  certain  anomalies  of  the  refraction,  as  hyperopia  and 
astigmatism,  and  of  accommodative  asthenopia  and  spasm  of 
the  ciliary  muscle. 

Diagnosis. — The  optic  papilla  appears  red,  and  new  vessels 
•are  developed  upon  its  surface  and  the  edge  of  the  disc,  which 
before  now  were  not  noticeable.  The  margin  of  the  disc 
becomes  less  distinct  and  ill-defined.  The  hypersemia  may  be 
so  marked  as  to  make  the  disc  appear  of  the  same  color  as  the 
fundus.  The  vision  is  not  affected.  The  light  may  or  may 
not  be  disagreeable. 

Treatment. — This  must  be  directed  to  the  cause  of  the 
hyperemia,  as  it  is  more  frequently  symptomatic  than  idio- 
pathic. Such  remedies  as  Bell.,  Duboisia,  Nux  vom.  and 
Phosph.  should  be  considered. 


NEURITIS  OPTICA— SYMPTOMS.  397 

NEURITIS  OPTICA. 

Causes. — Inflammation  of  the  optic  nerve  is,  in  general,, 
symptomatic  of  some  intra-cranial  disease.  It  may  arise  idio- 
pathically  in  depressed  conditions  of  the  system,  as  in  syph- 
ilis and  in  patients  suffering  from  various  toxic  influences  as 
tobacco,  alcohol  and  lead,  or  accompany  affections  of  the 
spinal  cord.  It  may  also  be  the  result  of  local  or  general 
disturbance  of  the  circulation,  anomalies  of  menstruation,  and 
uterine,  heart  or  kidney  diseases.  It  may  occur  during 
typhoid  fever  or  an  attack  of  facial  erysipelas.  Again,  inju- 
ries, orbital  cellulitis,  periostitis,  or  tumors  in  the  orbit  may 
be  the  exciting  causes.  The  majority  of  cases,  however,  are 
traceable  to  various  intra-cranial  diseases,  such  as  meningitis,, 
inflammation,  softening,  or  tumors  of  the  brain. 

Symptoms  and  Diagnosis. — Optic  neuritis  (Plate  V,  Fig.  3) 
can  be  recognized  by  the  ophthalmoscope  only.  It  may  exist 
without  diminution  of  vision,  or  the  failure  of  sight  may  be 
sudden  and  complete.  As  a  rule  there  is  generally  a  gradual 
loss  of  vision  which  can  not  be  accounted  for  by  manifest 
changes  in  the  superficial  portions  of  the  eye,  and  an  ophthal- 
moscopic examination  reveals  the  condition  of  the  optic  nerve. 
The  disc  appears  more  or  less  swollen,  its  surface  hyperaemic, 
the  lamina  cribrosa  is  obscured,  and  the  outlines  of  the  disc 
are  ill-defined,  irregular  and  the  optic  nerve  fibres  are  some- 
what opaque  from  infiltration  and  give  it  the  appearance 
known  as  ^'"wooly  disc.''''  The  veins  are  dilated  and  tortuous 
while  the  arteries  appear  smaller  than  normal,  and  the  vessels 
are  covered  here  and  there  by  the  swollen  tissue.  In  rare 
cases  spontaneous  arterial  pulsation  is  observ^ed.  Striated 
hemorrhages  upon  the  disc  or  in  the  retina  are  sometimes  seen. 
White  patches  of  sclerosis  or  fatty  degeneration  are  not  infre- 
quently obser^'ed  upon  the  disc  or  extending  into  the  retina. 
Yery  often  the  retina  is  clouded  by  infiltration  for  some 
distance  beyond  the  papilla.  If  the  inflammation  extends 
some  distance  into  the  retina  the  condition  becomes  one  of 
neuro-retinitis. 


898  DISEASES  AND  INJURIES  OF  THE  EYE. 

Cases  of  neuritis  in  which  there  is  great  swelling  of  the  optic 
disc,  with  hypersemia  and  tortuosity  of  the  retinal  veins,  but 
no  extensive  opacity  of  the  retina  constitute  what  is  known 
as  "  choked  disc.''  This  variety  of  neuritis,  which  was  first 
described  by  Von  Graefe,  is  dependent  upon  compression  of 
the  ocular  portion  of  the  nerve  by  fluid  or  inflammatory 
products  which  accumulate  in  the  inter-vaginal  space  between 
the  sheaths  of  the  optic  nerve.  This  space,  enclosed  by  the 
tough  dural  sheath,  is  continuous  through  the  optic  foramen 
with  the  meningeal  space  in  the  cranium  and  is  liable  to  disten- 
tion through  any  increase  of  fluid  within  the  meninges. 
Hence  this  form  of  neuritis  is  commonly  associated  with  intra- 
cranial disease.  The  unyielding  scleral  ring  in  addition  to  the 
lamina  cribrosa,  prevents  a  dilatation  of  the  opening  for  the 
entrance  of  the  optic  nerve,  so  that  any  compression  of  the 
nerve  behind  its  entrance  from  fluid  collected  in  the  sheath, 
-v^  ill  proportionately  retard  the  exit  of  venous  blood.  A  slight 
oedema  of  the  optic  disc,  results  which  tends  to  retard  the 
venous  flow  still  more  and  thus  increases  the  oedema.  The 
process  may  continue  until  inflammation,  degenerative  changes 
and  atrophy  occur.  The  trunk  of  the  nerve  is  believed  to  be 
healthy  in  the  majority  of  these  cases.  Our  knowledge  of  the 
changes  in  the  optic  nerve  which  produce  neuritis  optica  and 
their  relation  to  the  various  intra-cranial  diseases  which  so 
often  cause  or  accompany  the  inflammation,  is  as  yet  incom- 
plete. Many  of  the  cases  which  have  been  described  as  choked 
disc  may  be  due  to  the  extension  of  the  inflammatory  process 
along  the  nerve  as  in  the  so-called  "descending  neuritis." 
In  neuriiis  descendens,  a  not  uncommon  form  of  inflammation 
which  may  or  may  not  be  associated  vdih.  brain  disease,  the 
disc  is  congested  and  there  is  more  or  less  infiltration  of  tissue 
of  the  papilla. 

The  pathological  changes  of  the  papilla  in  choked  disc 
consist  of  the  separation  of  the  optic  nerve  fibre  bundles  by 
the  infiltrating  serum,  and  the  appearanca  of  varicose  swel- 
lings upon  the  fibres.  The  veins  become  increased  in  number 
and  calibre,  and  extravasations  of  blood  may  be  found  in  and 


NEURITIS  OPTICA— RETRO-BULBAR.  399 

upon  the  papilla.  There  is  rarely  any  hypertrophy  of  the 
connective  tissue  elements  of  the  nerve  unless  the  condition 
has  existed  for  a  long  time,  when  the  nerve  fibres  will  be  found 
atrophied.  In  the  other  forms  of  neuritis  which  are  marked 
by  much  greater  inflammation,  and  interstitial  changes,  there 
is  extensive  infiltration  of  cells,  increase  of  connective  tissue 
and  blood-vessels,  which  is  followed  by  degenerative  changes 
in  the  optic  nerve  fibres,  or  atrophy  ensues. 

Retro-hulbar  neuriUs  is  a  variety  of  neuritis,  also  observed 
by  Yon  Graefe,  in  which  there  is  loss  of  vision  associated  with 
dilation  of  the  pupil  which  is  preceded  by  a  slight  congestion 
of  the  papilla  and  without  inflammatory  symptoms.  Again 
there  may  be  slight  inflammation  of  the  nerve  observed  which 
continues  for  a  time  and  is  followed  by  atrophy.  Usually  but 
one  eye  is  affected.  The  loss  of  vision  may  be  partial  or  com- 
plete and  occur  within  a  few  hours  or  after  a  few  days.  '  There 
is  generally  no  pain,  except  possibly  a  headache.  There  is 
usually  central  scotoma  and  loss  of  color  perception.  With 
the  ophthalmoscope  the  disc  may  appear  normal,  or  present 
some  injection,  swelling  and  infiltration.  The  seat  of  lesion  is 
located  by  exclusion  in  the  orbital  portion  of  the  nerve  and 
may  follow  upon  typhoid  or  malarial  fevers,  measles,  menstrual 
disorders,  rheumatism,  syphilis,  etc. 

The  changes  which  are  observable  in  the  various  forms  of 
neuritis  are  not  always  limited  strictly  to  the  disc  as  in  a  true 
papillitis,  but  in  many  cases  there  is  more  or  less  haziness  and 
swelling  of  the  retina  which  may  extend  some  distance  from 
the  disc.  In  neuro-retinitis,  hemorrhages,  white  or  yellow 
dots  or  patches  will  be  found  in  the  disc  and  retina;  these 
cases  are  generally  presented  in  the  advanced  stage  of 
Bright' s  disease  or  may  be  due  to  cerebral  disease  and  albumen 
not  be  present  in  the  urine. 

Prognosis. — The  prognosis  as  regards  sight  will  depend 
upon  the  assumed  cause,  the  length  of  time  the  inflammatory 
process  has  existed  and  the  amount  of  tissue  change  which  may 
be  observed  with  the  ophthalmoscope.  The  prognosis  is 
generally  unfavorable.     The  Adsion  varies  greatly  during  the 


400 


DISEASES  AND  INJURIES  OF  THE  EYE. 


progress  of  the  disease,  and  the  ultimate  effect  upon  the  vision 
will  depend  upon  the  changes  which  occur  in  the  nerve  tissues. 
Eesolution  may  take  place  and  the  vision  be  largely  regained, 
or  consecutive  atrophy  result  with  perhaps  complete  destruc- 
tion of  vision. 

Treatment.— The  treatment  will  depend  somewhat  upon  the 
supposed  cause  of  the  affection.  Rest  of  the  eyes  becomes 
necessaiy,  all  near  work  should  be  avoided  and  the  eyes  pro- 
tected fi'om  the  light  by  smoked  glasses.  It  is  not  necessary 
to  confine  the  patient  to  a  darkened  room,  except  in  extreme 
cases  or  when  the  cerebral  disease  is  such  as  would  require 
close  confinement.  Proper  hygienic  regulations  should  be 
observed  in  all  cases.  The  remedies  which  will  likely  be 
indicated  will  depend  upon  the  exciting  cause  and  the  con- 
comitant symptoms  and  are  Bell.,  Duboisia,  Phos.,  Puis.,  Nux 
vom.,  and  Yerat.  vir. 

OPTIC  NERVE  ATROPHY. 

In  atrophy  of  the  optic  nerve,  we  distinguish  two  forms,  a 
primary  and  a  secondary  atrophy.  In  the  primary  form  the 
process  begins  in  the  nerve,  while  the  secondary  variety  is 
preceded  by  an  inflammatory  process. 

The  proper  classification,  however,  would  be  that  of  paren- 
chymatous and  interstitial,  as  the  pathological  changes  which 
occur  can  be  definitely  stated  as  due  to  sclerosis  or  fatty  degen- 
eration or  atrophy  of  the  parenchyma  of  the  nerve  fibres,  on 
one  hand,  or  result  from  increase  of  the  interstitial  connective 
tissue,  which  exists  between  the  nen-e  fibre  bundles  and  conse- 
quent compression  and  atrophy  of  the  nerve  cylinders. 

Causes. — AVhile  atrophy  is  the  natural  result  of  neuritis,  it 
may  also  arise  from  various  causes  which  lie  in  the  brain  or 
spinal  cord,  or  follow  injuries  of  the  globe  or  orbit.  Acohol- 
ism,  syphilis,  and  inflammatory  diseases  of  the  retina  or 
choroid  not  unfrequently  cause  it.  Among  other  causes 
which  may  be  mentioned  are,  the  toxic  effects  of  lead  and 
tobacco,  and    certain    diseases    as    facial    erysipelas,   measles. 


OPTIC  NERVE  ATROPHY.  401 

menstrual  derangements,  fevers,  diabetes  and  sclerosis  of  the 
spinal  cord.    In  some  cases  no  determinable  cause  can  be  found. 

Symptoms  and  Diagnosis. — The  visual  function  is  impaired, 
objects  appear  foggy  and  there  is  perhaps  over-sensitiveness 
to  the  light  which  is  followed  later  by  a  desire  for  strong  light. 
The  pupils  are  either  contracted  or  normal  and  sluggish.  The 
field  of  vision  becomes  contracted  and  the  color  perception, 
impaired  or  lost.  The  power  to  distinguish  green  is  first  lost, 
then  that  for  red,  and  finally  for  blue  and  yellow  when  the 
perception  for  color  has  entirely  disappeared.  In  certain 
cases  of  atrophy  due  to  alcohol  or  nicotine  poisoning  the 
first  color  which  is  lost  is  red,  or  there  may  be  only  a  central 
scotoma  for  red. 

The  atrophy  usually  affects  both  eyes  and  is  commonly 
associated  with  other  nervous  diseases,  particularly  of  the 
spinal  cord  and  due  inquiry  should  be  made  into  the  mental 
and  cerebral  symptoms. 

The  ophthalmoscopic  appearances  of  both  the  primary  and 
secondary  forms  are  somewhat  varied.  The  optic  disc  is 
opaque  and  white,  or  bluish  white,  and  the  capillaries  of  the 
disc  absent.  In  some  cases  the  lamina  cribrosa  may  be  seen 
and  appears  as  a  mixture  of  white  and  dark  dots  in  the  central 
portion  of  the  disc.  The  papilla  appears  flat,  or  concave  and 
excavated,  and  the  outline  of  the  disc  sharply  defined  if  the 
atrophy  is  well  advanced.  In  the  early  stages  of  the  secon- 
dary atrophy  the  disc  may  present  an  irregular  outline  and 
perhaps  patches  of  pigment  will  be  obser\^ed  around  it  as  in 
Plate  V,  Fig.  5.  The  vessels  are  diminished  in  number  and 
calibre,  and  sometimes  almost  entirely  absent.  In  some  cases 
of  progressive  atrophy,  the  retina  also  partakes  of  the  atrophic 
process  and  becomes  thinned,  so  that  the  choroidal  vessels 
become  very  prominent  as  in  Plate  Y,  Fig.  6.  In  the  primary 
form  of  atrophy  the  color  of  the  disc  is  usually  white  or  grey 
while  secondary  atrophy  presents  often  a  yellowish  appearance 
which  later  is  replaced  by  a  white  or  greyish  color. 

Teeatment. — The  treatment  consists  of  the  improvement  of 
the  general  health  by  promoting  the  general  nutrition.     All 

26 


402  DISEASES  AND  INJURIES  OF  THE  EYE. 

stimulants  and  tobacco  should  be  avoided.  The  remedies 
which  will  be  useful  in  atrophy  are  Strychnia,  Nux  vomica, 
Argent,  nit.,  Phosph.,  and  Zinc.  phos.  Occasionally,  when 
other  remedies  fail,  hyperdermic  injections  of  the  sulphate  of 
strychnia,  will  be  found  beneficial. 

AMAUROSIS  AND  AMBLYOPIA. 

Amaueosis  is  characterized  by  complete  blindness  with 
normal  ophthalmoscopic  appearances  of  the  interior  of  the  eye, 
as  well  as  the  absence  of  any  external  condition  to  account  for 
the  loss  of  vision. 

Amblyopia  is  that  condition,  where  there  is  partial  loss  of 
vision  which  is  neither  dependent  upon  any  refractive  error, 
nor  upon  any  discoverable  changes  in  the  normal  ophthal- 
moscopic appearances  of  the  fundus. 

Causes. — It  is  often  congenital  and  often  accompanies  high 
degrees  of  hyperopia,  myopia  or  astigmatism,  and  remains 
after  the  full  correction  of  the  ametropia.  It  is  also  present 
in  strabismus,  the  squinting  eye  rapidly  losing  vision,  the  cause 
being  supposed  to  be  due  to  the  fact  that  the  eye  does  not 
participate  in  the  visual  act,  and  the  condition  has  been 
termed  amblyopia  ex  anopsia.  Among  other  causes  may  be 
cited  injuries  to  the  globe,  as  blows  upon  the  eye  or  orbit  which 
cause  concussion  of  the  retina  without  any  visible  lesion  of 
the  eye.  In  these  cases  the  pupil  is  rigidly  contracted,  and 
the  vision  is  restored  after  a  few  days,  or  remains  impaired. 
Injuries  at  the  base  of  the  skull  not  infrequently  result  in 
complete  or  partial  loss  of  vision  without  perceptible  changes 
in  the  eye.  Concussions  and  injuries  to  the  spine  commonly 
produce  loss  of  vision  without  ophthalmoscopic  changes,  and 
the  amblyopia  follows  sometime  after  apparently  complete 
recovery  from  the  immediate  effects  of  the  injury,  and  is 
permanent.  Extensive  loss  of  blood  in  anaemic  patients  will 
sometimes  occasion  loss  of  %asion  which  may  be  partial  or 
complete  and  appear  immediately  upon  the  hemorrhage  or  not 
until  some  days    afterward.     Uraemia,  from    diseases  of   the 


AMAUROSIS  AND  AMBLYOPIA,  403 

kidney,  as  in  Brigbt's  disease,  and  as  found  in  diabetes 
frequently  produces  amblyopia  which,  may  be  temporary  or 
permanent  and  followed  by  atrophy  of  the  nerve.  It  also 
arises  from  poisoning  by  various  drugs,  as  lead,  quinine, 
salicylic  acid,  aniline  pigments,  as  well  as  silver  and  mercury. . 
Derangements  of  the  nervous  system,  such  as  hysteria  {ambly- 
opia hysterica),  paresis,  and  spasmodic  affections  are  causative. 
Again  it  may  arise  without  apparent  derangement  of  the 
health. 

Sexual  excesses  and  the  use  of  tobacco  [amblyopia  nico- 
iina)  and  alcoholic  stimulants  [amblyopia  potatorum),  either 
singly  or  together  produce  amblyopia.  In  the  amblyopia  of 
tobacco  and  alcohol  both  eyes  are  affected  and  the  condition 
may  arise  from  either  cause,  and  while  the  use  of  both  are 
commonly  combined  in  the  same  individual,  yet  undoubted 
cases  occur  in  which  the  effect  is  produced  by  one  or  the  other. 

Chronic  alcoholism  has  long  been  recognized  as  productive 
of  loss  of  vision  and  of  optic  nerve  atrophy.  The  ophthalmo- 
scopic appearances  are  usually  a  dull  red  disc  with  perhaps  a 
hazy  border  and  a  torpid  circulation  of  the  fundus  as  evinced 
by  the  swollen  veins.  There  is  often  an  anaesthetic  condition 
of  the  retina  and  later  contraction  of  the  visual  field,  and 
impairment  of  color  perception. 

Tobacco  poisoning  exhibits  still  fewer  ophthalmoscopic 
lesions,  the  nerve  is  more  nearly  normal,  brighter  in  color, 
and  later  shows  signs  of  inflammation  or  interstitial  atrophy. 
The  vision  is  often  much  reduced  but  there  is  rarely  any  con- 
traction of  the  field  of  vision.  There  is  very  frequently  a  central 
scotoma  for  red,  which  has  been  considered  diagnostic.  The 
central  vision  may  remam  good  for  light  and  form  in  these 
cases,  but  there  is  inability  to  distinguish  red  tints  in  this 
portion  of  the  field.  In  either  of  these  two  forms  of  ambly- 
opia the  loss  of  vision  may  come  on  insidiously  and  without 
headache  or  other  symptoms.  Inquiry  in  the  majority  of 
cases  will  however  reveal  the  fact  that  the  stomach  has  become 
deranged  and  that  there  is  nausea  and  rejection  of  food 
particularly  in  the  morning. 


404 


DISEASES  AND  INJURIES  OF  THE  EYE. 


Treatment. — The  treatment  of  amblyopia  is  dependent 
entirely  upon  the  cause,  which  is  to  be  removed.  When 
dependent  upon  injuries  and  general  diseased  conditions  these 
demand  immediate  treatment  and  the  amblyopia  may  disap- 
pear with  the  relief  of  the  primary  symptoms,  or  if  persistent 
requires  such  medical  treatment  as  may  be  indicated  by  the 
cause  or  concomitant  symptoms.  When  excesses  in  venery, 
tobacco  or  alcohol,  give  rise  to  the  condition,  absolute  absti- 
nence is  demanded,  and  if  the  disc  is  normal  and  the  field 
not  limited,  the  abandonment  of  all  indulgence,  together  with 
the  use  of  such  remedies  as  Strycli.,  Nux  vom.,  Arsenicum, 
and  Phosph.  will  result  in  complete  recovery. 

Simulated  Blindness. — Loss  of  vision  is  sometimes  feigned 
for  the  purpose  of  escaping  the  performance  of  duty,  to 
excite  sympathy,  or  to  recover  damages  for  slight  injuries. 
If  the  amaurosis  is  claimed  to  affect  both  eyes,  it  becomes  a 
difficult  matter  to  determine  the  malingering  when  the  ophthal- 
moscopic appearances  are  normal.  In  the  amaurosis  of  both 
eyes,  which  occurs  from  other  causes  than  uraemia,  the  pupils 
are  somewhat  dilated  and  immovable,  but  the  dilatation  is  not 
as  great  as  that  which  follows  the  instillation  of  atropine.  If 
the  blindness  is  pretended  it  may  be  detected  by  any  variation 
in  the  action  of  the  iris  under  the  influence  of  alternate  light 
and  darkness,  or  by  bringing  an  instrument  suddenly  from 
above  directly  in  front  of  the  eye  when  a  natural  closure  of 
the  lids  occurs  to  prevent  impending  injury  to  the  eye  when, 
vision  exists. 

When  the  imposition  exists  for  only  one  eye,  it  is  more 
easily  determined.  In  this  case  if  a  prism  of  ten  or  fifteen 
degrees  is  placed  before  the  healthy  eye,  with  the  base  either 
up  or  down,  and  if  the  patient  sees  the  dot  on  the  line  double 
as  in  the  insufficiency  of  the  recti  muscles  in  asthenopia, 
the  imposition  becomes  apparent  at  once.  Other  tests  may 
be  made  with  the  stereoscope,  the  slides  being  so  arranged 
that  the  picture  before  the  healthy  eye  is  darkened,  while  that 
before  the  supposed  blind  eye  is  clear,  or  a  cross  may  be 
placed  on  the  slide  before  one  eye  while  a  circle  is  fixed  before 


TUMORS  OF  THE  OPTIC  NERVE.  405 

the  other;  where  there  is  binocular  vision  the  patient  sees  a 
<;ross  within  the  circle. 

In  all  cases  great  care  must  be  exercised  to  prevent  the 
patient  from  suspecting  that  the  methods  employed  are  to 
discover  the  dissembling,  and  he  should  be  given  to  under- 
stand that  the  desire  is  only  to  determine  the  cause  of  the 
amaurosis. 

TuMOKS  OF  THE  OPTIC  NERVE  are  very  rare  and  may  be 
neuromata,  carcinomata,  or  cystic,  and  may  develop  in  the 
cranial  or  orbital  portions  of  the  nerve.  There  is  usually  a 
marked  neuro-retinitis  during  the  development  of  the  tumor,  or 
an  exopthalmus  when  the  growth  involves  the  orbital  portion — 
when  the  tumors  are  within  the  orbit  an  operation  is  indicated 
and  enucleation  or  extirpation  of  the  contents  of  the  orbit 
"will  become  necessary.  Glioma  may  arise  in  either  the 
retina  or  optic  nerve,  and  when  developing  within  the  globe 
frequently  extends  backward  to  the  brain  when  unchecked  by 
€arly  removal 


INDEX 


ABBREVIATIONS     and     signs    for 

lenses,  98,  99 
Abrns  prsecatorius,  225 
Abscess  of  cornea,  253 
eyelid,  169 
frontal  sinns,  148 
lachrymal  sac,  168 
globe,  355 
Absorption  of  cataract,  316 
Accommodation,  15,  27,  71 

action  of  atropia  upon,  46 
action  of  calabar  bean  upon,  46 
action  of  eserine  upon,  46 
anomalies  of,  295 
changes  in, 16 
diseases  of,  295 
paralysis,  295 
paresis,  296 
in  presbyopia,  72 
in  spasm,  299 
examination  of,  27 
muscle  of,  7 
negative,  72 
power  of,  73 
range  of,  27,  71 
absolute,  72 
monocular,  72 
binocular,  119 
negative,  28,  72 
positive,  28.  72 
relative,  28,  72 
Accommodative  asthenopia,  77,  297 

movements,  16 
Acne  ciliaris,  174 
Acuity  of  vision,  26 

modes  of  estimating,  26 
Acute  retinitis,  378 

Adams'  operation  for  ectropium,  187 
Adhesions  of  the  pupil,  272 
Advancement,  operation  of,  128 
in  muscular  paralysis,  128 
^gilops,  170 


Affections  of  the  muscles  of  lids,  190, 

191 
After-images,  386 
After-treatment    oi;    cataract    operit- 

tions,  236 
Albinos,  38 

Albinism  of  the  choroid,  357 
Albuminuric  retinitis,  380 
Alcohol,    a    cause    of    optic    nerve 
atrophy,  403 

a  cause  of  conjunctivitis,  202 
Alcoholic  amblyopia,  403 
Allen,  Dr.  T.  F.,  on  use  of  Lachesis, 

136 
Alternating  squint,  118 
Alum,  166 

Alumen  exsiccatum  pulv.,  163 
Amaurosis,  402 

simulation  of,  404 
Amblyopia,  118 

exanopsia,  120,  402 

anaemic,  402 

from  alcohol  and  tobacco,  403 

from  blood  poisoning,  403 

congestive,  403 

from  non-use,  402 

from  quinia,  403 

potatorum,  403 

in  pregnant  women,  with  albumi- 
nuria, 402 

saturnina,  403 

in  strabismus,  118,  120 

from  tobacco,  403 

uraemic,  402 
Ametropia,  66 

in  strabismus,  119 
Amyloid  degeneration  of  conjunctiva, 

223 
Anaemia,  141 

Anaemia  of  the  retina,  375 
Anaesthetics,  41 

in  cataract  operations,  331 


408 


INDEX. 


Anaesthetics  in  strabismus  operations, 

123 
Anaesthesia  of  the  cornea,  364 

of  the  retina,  383,  388 
Anatomy  and  physiology,  general,  1 
Anchyloblepharon,  195 
Anchylops,  170 
Anel's  canalicnlns  probe,  154 
Aneurism  of  ophthalmic  artery^  147 

of  orbit,  147 
Angiomata,  142 
Angle  alpha,  66 

of  vision,  66 

of  the  iris,  12 
Anisometropia,  99 
Anomalies  of  refraction,  64 
Anterior  chamber,  4,  6,  6, 12 

ciliary  arteries,  10 

ciliary  veins,  12 

elastic  lamina,  235 

polar  cataract,  338 

pole,  3 

vascular  zone,  23 
Antero-posterior  diameter  of  the  eye- 
ball, 2 
Anthrax  of  the  eyelids,  171 
Antrum  of  Highmore,  130,  149 

injury  of,  51 

tumors  of,  149 
Aphakia,  339 
Apoplexy  of  the  retina,  376,  378 

of  the  choroid,  357 
Aqua  chlori,  145 
Aqueous  humor,  4 

evacuation  of,  245 
in  iritis,  245 
keratitis,  245 
Aquo-capsulitis  [Vide  Decemetitis] 
Arachnoidal  space,  9, 132 

cavity,  13 
Arcus  senilis,  258 
Arlt,  blepharoplastic  operation,  189 

operation  for  pterygium,  232 
Aspirator,  use  of  in  periostitis,  138 
Arteria  centralis  retinae,  11 

hyaloidea,  341 
Arteries  of  eye,  10 

central,  8 

anterior  ciliary,  10 

long  ciliary,  10 

short  ciliary,  10 

posterior  ciliary,  10 
Arterial  loops  of  cornea,  11 
Artificial  eye,  308 

pupil,  286 
Associated  action  of  ocular  muscles, 

•      104 
Asthenopia,  77 

accommodative,  77 

due  to  hypermetropia,  77 

muscular,  77,  113 


Asthenopia,  retinal,  386 
Asthenopic  headaches,  95, 114 
Astigmatism,  16,  67,  92 

acquired,  93 

causes,  93 

compound,  94 

congenital,  93 

diagnosis  of,  95 

hyperopic,  94 

irregular,  93 

mixed,  94 

myopic,  94 

regular,  93 

simple,  94 

ophthalmoscopic  diagnosis  of,  95 

symptoms,  94 

treatment  of,  97 

test  cards  for,  96 
Ataxy,  locomotor,  a  cause  of  amauro- 
sis, 401 
Atresia  of  the  lachrymal  puncta,  154 
Atrophy  of  the  bulb,  210 

of  the  optic  nerve,  24,  400 
Atropia,  sulphate  of,  45,  98 

action  of,  on  accommodation,  46,    * 
296 
on  the  iris,  46,  284 

anomalous  effects  of,  46 

in  glaucoma,  363 

in  iritis,  274 

in  myopia,  90 

poisonous  symptoms,  46 

strength  of  solution,  46 
Atropiae  sulphatis,  45 
Atropine  conjunctivitis,  206 
Autumnal  conjunctivitis,  205 
Axis,  optic,  3 

length  of,  65 

visual,  3 

length  of,  66 

BACILLI  of  retina,  373 
Bandage,  forms  of,  42,  43 

compress,  24 
Bandaging,  42 

Basedow's  disease,  20,  137,  140 
Beer's  knife,  49 
Bicarbonate  of  soda,  52 
Binocular  vision,  17 

mode  of  examination  of,  404 

in  strabismus,  122 
Blackboard  for  recording  visual  field, 

25 
Black  eye,  52 

Blennorrhcea  of  lachrymal  sac,  164 
Blepharitis  acuta,  169 

margin  alls,  174 
Blepharo-adenitis,  174 
Blepharoplasty,  189 
Blepharospasm,  192 
Blind  spot  of  Mariotte,  17  » 


INDEX. 


409 


Blindness  simulated,  404 
Blood-vessels  of  globe,  10 

of  macula  lutea,  373 

of  retina,  374 
Blood  effused  into  anterior  chamber, 
58 

into  choroid,  63 

into  conjunctiva,  198 

into  eyelids,  62 

into  orbit,  51 

into  retina,  376 

into  vitreous  humor,  61,  345 

supply  of  eyeball,  10 
Blue  glasses,  70 

ointment,  176 
Boll,  discovery  of  retinal  purple,  17 
Bonnet,  capsule  of,  101 
Bony  tumor  of  orbit,  144 
Borax,  165 
Boracic  acid,  45,  155 
Bowman's  membrane,  235 

canaliculus  knife,  157 

probes,  159 
use  of,  157 
Brachymetropia  (vide  Myopia),  345 
Brain  tumor,  a  cause  of  neuritis,  397 
Bright's  disease,  a  cause  of   retinitis, 

380 
Brunettes,  retina  of,  38 
Bulbus  oculi  (vide  Eyeball) 
Buphthalmos,  266 
Burnett,  205 
Burns,  52,  53 

from  ammonia,  53 

from  acids,  53 

of  conjunctiva,  53 

of  lids,  52 

from  lime,  53 

from  mortar,  53 

from  molten  metals,  53 

CALABAR  bean  (vide  Eserine) 
Calcareous  deposits  on  cornea,  258 

in  meibomian  glands,  231 
Calculus,  lachrymal,  155 

meibomian,  231 
Calendula,  45,  52 
Calomel,  228 
Canal  of  Petit,  312 

of  Schlemm,  5,  7,  12 
Canaliculus,  lachrymal,  2 

division  of,  154 

obstructions  in,  153 

probe,  154 
Canalus  opticus,  13 
Cancer  of  choroid,  356 

of  conjunctiva,  234 

of  cornea,  261 

epithelial,  194,  234,  261 

glio-sarcoma,  144 

of  eyelids,  194 


Cancer  of  iris,  282 

medullary,  144 

of  the  retina,  390 

of  orbit,  144 
Canthi,  167 

Canthoplasty,  185,  186 
Canthotomy,  185,  217 
Canthus,  external,  167 

internal,  167 
Capsule  of  Bonnet,  101 

of  Tenon,  2,  13,  101,  132 
inflammation  of,  139 

of  lens,  312 
Capsular  cataract,  338 

anterior,  338 

posterior,  338 
Capsulitis,  132,  139 
Carbolic  acid,  155,  510,  225 
Carbuncle  of  the  eyelids,  171 
Caries  of  the  orbit,  139 
Carter's  test-cards,  96 
Cartilage,  tarsal,  168 
Cartilaginous  tumors  of  the  orbit,  144 
Caruncle,  195 

inflammation  of,  231 
Caruncula  lachrymalis,  196 
Cataract,  313 

anterior  capsular,  338 

atropia  in,  314 

black,  325 

capsular,  245 

causes,  60,  313 

chalky,  324 

complications,  326 

congenital,  315 

cortical,  321 

diabetic,  313 

diagnosis  of,  314 

duration  of,  325 

etiology  of,  313 

glaucomatous,  366 

hard,  322 

hypermature,  324 

immature,  324 

lamellar,  319 

mature,  324  i 

mixed,  321  ' 

Morgagnian,  324 

nuclear,  322 

polar,  338 

posterior  capsular,  338 

pyramidal,  245, 338 

secondary,  339 

soft,  315 

symptoms  of,  314 

traumatic,  316 

varieties  of,  313 

zonular,  319 
Cataract,  treatment  of,  316,  320,  327 

by  couching,  330 

by  discission,  316 


410 


INDEX. 


Cataract,  treatment  of,  by  flap  extrac- 
tion, 330 

by  Von  Graefe's  extraction,  331 

by  linear  extraction,  318 

by  removal  of  lens  in  its  capsule, 
338 

by  reclination,  330 

by  scoop  extraction,  338 

by  suction,  319 
Catarrhal  ophthalmia,  201 
Cats'-eye,  amaurotic,  (glioma  retinae) 

390 
Caustics,  161,  247 

use  of,  161,  224 
Caustic,  mitigated,  224 
Cautery,  galvanic,  161 
Cavernous  sinus,  11,  132 

thrombus  of,  147 
Cavity,  arachnoidal,13 
Cells,  endothelial,  of  iris,  8 

ganglionic,  of  retina,  8 

laminated,  of  retina,  8 
Cellulitis,  orbital,  133 
Central  artery  of  retina,  9,  11 
Centre,  optical,  66 

of  rotation,  2 
Cerebral  oedema  a  cause  of   neuritis, 

398 
Chalazion,  173 
Chamber,  anterior,  4,  12 

effusion  of  blood  into,  58 

posterior,  4,  12 
Chemosis  of  conjunctiva,  198 
Chloral,  204 
Chlorine  water,  45 
Chloroform,  41 

in  cataract  operations,  331 

in  diphtheritic  conjunctivitis,  219 
Choked  disc,  144.  398 

pathology  of,  398 
Cholesterine  crystals  in  lens,  324 

ia  vitreous,  344 
Chorea,  95,  114 
Choroid,  4,  6 

anaemia  of,  351 

anatomy  of,  6,  347 

atrophy  of,  350 

bony  deposit  in,  303 

cancer  of,  356 

colloid  disease  of,  356 

coloboma  of,  357 

detachment  of,  57.  357 
Choroid,  diseases  of,  348 

hemorrhage  from,  61 

injuries  of,  63 

hypersemia  of,  350 

layers  of,  6,  347 

pathological  changes  of,  in  M,  87 

rupture  of,  356 

sarcoma  of,  356 

tubercles  of,  356 


Choroid,  tumors  of,  356 
Choroidal  ring.  37,  395 
Choroiditis,  348 

areolaris,  354 

causes,  349 

diagnosis,  350 

disseminata,  353 

metastatica,  355 

plastica,  352 

serosa,  357  ; 

symptoms  of,  349 

suppurative.  355 

syphilitic,  363 
Cilia,  168 
CiUary  arteries,  10 

anterior,  10  j 

long,  10 

short,  10 
Ciliary  body,  4,  7,  16 

anatomy  of,  291 
hyperaemia  of.  78 
diseases  of,  292 
congestion  of,  13 

ganglion,  9,  10 

muscle,  7,  9 

affections  of,  296 
anatomy  of, 
atoiiy  of,  297 
paralysis  of,  295 
spasm  of,  299 
Ciliary  neuralgia,  272 

processes,  4,  6 

region,  injuries  of,  295 

spasm,  114 

veins,  anterior,  12 

zone,  272 
Circles  of  diffusion,  84 
Circular  venous  sinus,  5 
Circulation  of  nutrient  fluid,  11,  12 

of  lymph,  11, 12 
Circulus  arteriosus  major  iridis,  270 
jninor  iridis,  270 
Coccius,  29 
Cleansing  the  eye,  45 
Clamp  forceps.  174 
Cold  applications,  44 
Coloboma  of  choroid,  357 

of  iris,  282 

of  lids,  194 
Collodion,  183 

Colloid  disease  of  choroid,  356 
Collyria,  203,  213,  224 
Color,  test  for,  24 
Color  blindness,  24,  390 

tost  for  (Holmgren's),  24 
Color  of  eye,  268 

perception,  390 

scotomata  in  optic  nerve  atrophy, 
401,  403 
in  tobacco  amblyopia,  403 
Coloring  matter  of  retina,  8 


INDEX. 


411 


Compression,  digital,  in  orbital  aneu- 
rism, 147 
Concomitant  squint,  118 

strabismus,  118 
Condition  of  the  lids,  to  examine,  20 
Conducting  filaments,  8 
ConeSj  layer  of,  8,  373 
Confusion  test,  24 
Conical  cornea,  259 

treatment  of,  259 

Bowman's  operation,  161 
by  iridectomy,  260 
Von  Graef e's  operation,  '260 
Conjugate  foci,  65 

law  of,  19 
Conjunctiva,  2,  52,  53 

amyloid  degeneration  of ,  223 

anatomy  of,  196 

bulbi,  166 

burns  of,  53 

cul-de-sac  of,  196 

cysts  of,  234 

dermoid  growths  of,  234 

diseases  of,  196,  197 

dislocation  of  lens  beneath,  59 

emphysema  of,  198 

epithelial  cancer  of,  234 

examination  of,  21 

hemorrhage  into,  198 

foreign  bodies  upon,  53 

hyperaemia  of,  199 

injuries  of,  52 

inflammation  of,  200 

lupus  of,  234 

pigment  deposits  of,  234 

oedema  of,  198 

Pinguecula  of,  233 

polypus  of,  233 

sarcoma  of,  23r 

syphilitic  ulcer  of,  234 

tumo  -3  of,  233 

warts  of,  234 

wounds  of,  53 
Conjunctival    discharge,   contagious- 
ness of,  206,  216,  221 
Conjunctivitis,  200 

from  atropine,  206 

autumnal,  205 

blennorrhceic,  207 

catarrhal,  200,  201 

chronic.  202 

croupous,  200,  217 

diphtheritic,  200,  218 

follicular,  226 

gonorrhoeal,  200,  208,  214 

granular,  209 

membranous,  217 

palpebral,  199 

phlyctenular,  200,  227 

purulent,  200,  206,  209 

pustular,  227 


Conjunctivitis,  simple,  200,  201 
spring,  205 

trachomatous,  200,  219 
vernal,  205 
Contagious  diseases  of  eye,  200 
Contusions  of  eyelids,  52 
Convergent  strabismus,  118 
Copper  sulphate,  224 
Corelysis,  290 
Cornea,  4,  235 

abrasions  of,  55 

abscess  of,  253 

anaesthesia  of,  256 

anatomy  of,  5,  235 

diseases  of,  238 

examination  of,  22 

fistula  of,  245,  247 

focal  length  of,  65 

foreign  bodies  in,  54 

globosa,  269 

hernia  of,  244 

herpes  of,  238 

inflammation  of,  239 

injuries  of,  54 

neuro-paralytic  affection  of,  256 

nerves  of,  5,237 

opacities  of,  257 

paracentesis  of,  245 

perforation  of,  244 

sloughing  of,  134 

staphyloma  of,  259 

suppuration  of,  253 

after  cataract  extraction,  337 
trephining  of,  261 
Cornea,  tumors  of,  261 
ulcers  of,  213,  242 
asthenic,  243 
causes,  242 
chipping,  243 
crescentic,  244 
perforating,  243 
sthenic,  242 
superficial,  243 
symptoms,  243 
transparent,  243 
treatment  of,  245 
vascular,  244 
wounds  of,  56 
Corneal  corpuscles,  236 
ulcers,  242 
fistula,  245 
Corpora  g'rniculata,  8,  393 

quadrigemina,  8, 393 
Cosmoline,  209 
Couching  330 
Cream,  use  of,  in  burns,  53 
Crystalline  lens  [see  Lens] 
Cul-de-sac  of  conjunctiva,  196 
Cyclitis,  293 

sympathetic,  61,  304 
traumatic,  295 


412 


INDEX. 


Cylindrical  glasses,  99 

lenses,  99 

use  of,  in  astigmatism,  99 
Cyst  of  eyelids,  173 

of  conjunctiva,  234 

in  iris,  282 

of  orbit,  142 

tarsal,  173 

meibomian,  173 
Cystic  tumors,  142,  173,  234,  282 
Cysticercus,  of  the  orbit,  142 

in  vitreous  humor,  346 
Cystoid  cicatrix  in  glaucoma,  370 

DACRYO- adenitis,  152 

Dacryo-cysto-blennorrhoea,  163 

Dacryo-cystitis,  162 

Dacryoliths,  155 

Dacryops,  153 

Daltonism  {vide  Color  blindness) 

Decoction  of  chamomile,  45 

calendula,  45 

hops,  45 
Decussation  of  optic  nerve  fibres,  9, 

393 
Defects  of  normal  eye,  16 
Delivery  of  lens,  335 
Dermoid  tumors  of  conjunctiva,  234 
Descemititis,  256 
Descemet's  membrane,  12,  236 
Desmarre's  elevator,  47 

damp  forceps,  174 

paracentesis  knife,  245 
Destruction  of  lachrymal  sac,  161 
Detachment  of  the  retina,  57,  384 

choroid,  67,  357 

iris,  68 
Detailed  examination,  70 
Deviation,  primary,  of  visual  lines,  104 

secondary,  of  visual  lines,  104 

in  hypermetropia,  104 

in  myopia,  104 

in  paralytic  affections  of  the  ocu- 
lar muscles,  105 
Deviation  in  strabismus  concomitans, 

120 
Deviation,  primary,  104 

secondary,  104 
Diagnosis     of    ametropia     with   the 

ophthalmoscope,  78,  89,  95 
Diagrammatic  eye,  14 
Diameters  of  eyeball,  2,  3 
Diflfenbach's     operation     for     ectro- 

pium,  187 
Digital  pressure  in  orbital  aneurism, 

147 
Dilatation  of  pupil,  46,  283 
Dilator  muscle,  7,  269 
Dioptric  apparatus  of  the  eye,  14 

system,  68 

unit  of,  68 


Dioptrics,  table  of,  67 
Diphtheria,  218 
Diptheritic  conjunctivitis,  218 
Diplopia,  17,  104,  105,  108 

binocular,  105 

crossed,  105,  106 

direct,  105 

hieronymous,  105 

homonymous,  105, 

monocular,  106 

operation  for,  113 

treatment  of,  112 
Direct  examination  with  the  ophthal- 
moscope, 34 
Disc,  optic,  9,  37 

choked,  144 
Discission,  60 

Diseases  of  the  muscles  of  the  eye, 
107 

eyelids,  168 

ciliary  body,  292 

choroid,  348 

conjunctiva,  146  • 

cornea,  238 

iris,  270 

lachrymal  apparatus,  160 
gland,  162 

lens,  313 

lids,  168 

optic  nerve,  399 

orbit,  132 

retina,  375 

sclera,  263 

vitreous,  342 
Disinfecting  lotions,  45 
Dislocation  of  the  eye,  92 

lens,  60,  339 
Distichiasis,  180 
Divergent  strabismus,  126 
Division  of  cataract,  316 

ciliary  muscle,  370 

supra-orbital  nerve,  192 
Donders,  Prof.,  73,  76 

on  glaucoma,  363 

on  hyperopia,  80 

on  myopia,  76 

on  near  point,  73 
Double  vision,  17,  104, 106 
Douche,  45 

Drainage  of  the  eye,  12,  863 
Dropsy  of  the  eye,  266 
Duboisia,  90  46,  117,  200 

sulphate  of,  46 

solution  of,  46 

poisonous  symptoms  of,  47 
Duct,  lachrymal,  161 

obstruction  of,  154 

nasal,  151 

strictures  of,  154 
Dural  sheath,  394 
Dura  mater,  9,  394 


INDEX. 


413 


ECCENTRIC  vision,  25 
Ecchymosis  of  conjunctiva,  188 

of  eyelids,  52 
Echinococcus  in  orbit,  142 
Ectopia,  283 

lentis,  339 
Ectropium,  186 

causes,  186 

operations  for,  Adams',  187 
Diffenbach's.  187 
Graefe's,  188 
Wharton  Jones',  187 

treatment  by  blepharoplasty,  189 
tarsoraphia,  188 
Eczema  of  the  lids,  193 
Effusion  of  blood  into  anterior  cham- 
ber, 58 

into  choroid,  63 

conjunctiva,  198 
eyelids,  52 
retina,  376 
vitreous  humor,  67 
Egyptian  ophthalmia,  220 
Electricity  in  paralysis  of  ocular  mus- 
cles, 111 
Electrolysis,  148 

in  lachrymal  stricture,  160 
Elements,  percipient,  of  retina,  8 
Elevator,  lid,  Desmarre's,  47 
Embolism  of  retinal  artery,  376 
Emmetropia,  C6 
Emphysema  of  eyelids, 

of  conjunctiva,  198 
Encanthus,  234 
Enchondroma  of  orbit,  144 
Encysted  tumor  of  lids,  173 

of  orbit,  144 
Engorged  papilla  (choked   disc),  398 
Entoptic  phenomena,  16 
Entozoa  {vide  Cysticercus  and  Echino- 
coccus,) 
Entropium,  183 

acute  or  spasmodic,  183 

chronic,  183 

senile,  183 

treatment  of,  184 

Hotz'  operation  for,  185 
Enucleation  of  eyeball,  62,  307 
Epicanthus,  194,  234 
Epilation,  180 
Epiphora,  153 
Episcleritis,  265 
Epithelioma,  194 

of  conjunctiva,  233 

of  cornea,  261 

of  lids,  194 
Equator  of  globe.  4,  7 
Erectile  tumors  of  eyelids,  194 

of  orbit,  145 
Errors  of  refraction,  54 
Erysipelas,  133 


Erysipelas  of  eyelids,  172 

facial,  140 
Erythema  of  eyelids,  133 
•Eserine,  41,  245 

sulphate  of,  47 

use  of,  47 

solution  of,  47 
Ether,  41 

Ethmoid  cells,  distention  of,  148 
Evacuation  of  aqueous  humor,  245 

of  the  eyeball,  259 
Eversion  of  lids,  186 
Evisceratio-bulbi,  259 
Examination  of  eye,  20 

by  lateral  illumination,  28 

by  focal  illumination,  28 

ophthalmoscopic,  29 
Excavation  of  optic  nerve,  395 

atrophic,  401 

glaucomatous,  364 

physiological,  37,  395 
Excision  of  eyeball,  307 

of  staphyloma,  259 
Excoriation  of  lids,  175 
Exit  for  aqueous  fluid,  6 

for  lymph,  12 
Exophthalmic  goitre,  140 

symptoms  and  diagnosis,  140 

treatment,  141 
Exophthalmus,  132,  137 
Exostosis  of  orbit,  144 
External  rectus  muscle,  9 

paralysis  of,  110 
Extraction  of  hard  cataract,  329 

of  foreign  bodies  from  the  eye,  62 
Extirpation  of  eyeball,  307 

of  lachrymal  grand,  153 

of  lachrymal  sac,  161 
Extraction  of  lens,  318,  339 

by  flap  operation,  330 

by  Von  Graefe's  operation,  330 

by  linear  incision,  318 

Liebreich's  method,  337 

LeBrun's  method,  337 

by  scoop  operation,  338 

by  suction,  319 

in  its  capsule.  338 
Eye,  ametropic,  66 

anatomy  of,  1 

artificial,  308 

diagrammatic,  of  Listing,  14 

douche,  45 

emmetropic,  66 

enucleation  of,  307 

examination  of,  19 

general  inflammation  of,  355 

injuries  of,  50 

lashes,  168 

myopic,  67,  90 
Eye-glasses,  68 

shades,  44 


414 


INDEX. 


Eyeball,  atrophy  of,  134 

blood  supply,  10 

displacement  of,  137, 142, 143 

lymphatic  system  of,  11 

prominence  of,  20 

protrusion  of,  132 
causes,  132 
Eyelashes,  inversion  of,  180,  183 

transplantation  of,  182 

removal  of,  180,  181 

to  destroy  bulbs,  182 
Eyelids,  abcess  of,  169 

affections  of,  168 

anatomy  of,  167 

anthrax  of,  171 

baldness  of,  175 

blepharo-adenitis,  174 

blepharospasm,  192 

bums,  52 

contusion  of,  52 

carbuncle  of,  171 

chalazion,  173 

diseases  of,  167,  168 

distichiasis,  180 

ecchymosis  of,  52 

eotropium,  186 

eczema  of,  193 

emphysema  of,  169 

encysted  tumors  of,  173 

entropium,  183 

epicanthus,  194 

epithelial  cancer  of,  194 

erysipelas  of,  172 

erythema  of,  172 

to  evert,  21 

eversion  of,  186 

herpes,  193 

hordeolum,  172 

hyperaemia  of,  172 

inflammation  of  edges  of,  174 

injuries  of,  51 

inversion  of,  183 

malignant  pustule  of,  171 

nsBvus  of,  194 

oedema  of,  169 

to  open,  20 

paralysis  of  upper,  110 

ptosis  of,  190 

spasm  of  orbicularis  of,  192 

tinea  tarsi,  174 

trichiasis,  180 

tumor  of,  195 

ulcers  of,  syphilitic,  193 

•warts  on,  194 

wounds  of,  52 
Examination  of  eye,  methods  of,  19 

detailed,  20 

general,  19 
Exophthalmus,  132 

FARAD AISM  in  paralysis,  111,191, 102 


Faradaism  in  asthenopia,  115 

Far  point,  71 

Far  sight  {vide  Hypermetropia) 

Farsightedness  (vide  Hypermetropia) 

Fascia,  oculo-orbital,  132,  168 

tarso-orbital,  132,  168 
Fatty  degeneration  of  retina  in  retin- 
itis albuminurica,  380 
Fibres  of  optic  nerve,  394 
Fibroma  of  orbit,  142 
Fibromata,  142 
Field  of  vision,  17,  24,  25 

for  colors,  26 

contraction  of,  365,  383,  401 

in  detached  retina,  384 

in  injuries  of  vitreous,  61 

in  glaucoma,  365 

in  retinitis  pigmentosa,  383 

false  projection  of,  in  diplopia,  108 

equilateral  or  homonymous   con- 
traction of,  389 

examination  of,  25 
Fissura  palpebrarum,  167 
Fissure,  inferior  orbital,  131 

spenoidal,  131 

spheno-maxillary,  131 

superior  maxillary,  131 

palpebral,  167 
Fistula  cornese,  245 

of  cornea,  245 

lachrymalis,  162 

of  lachrymal  sac,  162 
Fixation,  central,  24 

eccentric,  25 

forceps,  49 
Flap  extraction  of  cataract,  330 
Flashes  of  light  in    eye   {vide  Phos- 

phenes) 
Flax-seed  poultices,  45 
Fluid  cataract,  324 

vitreous,  344 
Focal  distance  of  lens  system,  65 

illumination,  28 

length  of  cornea,  65 

of  lens,  65 

Focus,  principal  posterior,  15 

principal,  of  cornea  and  lens,  65 
of  lenses,  65 
Foci,  conjugate,  65 
Fold,  retro-tarsal,  196 
Fomentations,  hot,  44 
Forceps,  fixation,  49 
Foreign  bodies  on  the  conjunctiva,  6^ 

in  ciliary  body,  62 

on  cornea,  54 

to  detect,  28 

in  eye,  62 

hook  for,  62 

on  iris,  58 

in  lachrymal  apparatus,  52 

in  lens,  60 


INDEX. 


415 


Foreign   bodies   within   the   eyeball, 
magnet  for,  62 

in  orbit,  51 

in  vitreoas,  61 
Fornix  of  conjunctiva,  196 
Fossa,  hyaloid,  341 

patellaris,  341 
Fourth  nerve,  9 
Fovea  centralis,  8,  15.  372 

to  examine,  38,  375 
Fractures  of  walls  of  orbit,  50 
Frog-spawn  granulations,  220 
Frontal  sinus,  abscess  of,  148 

distention  of,  148 
Fundus  oculi,  37 

of  brunettes,  38 

ophthalmoscopic  appearances  of 
healthy,  37 
of  Negroes,  38 
of  Albinos,  38 

cause  of  color  of,  38 
Fungus  haematodes,  392 

GALVANISM  in  muscular  paralysis, 
111,  191 
in  muscular  asthenopia,  115 
in  exophthalmic  goitre,  141 
Galvano-caustic,  161 
Galvanic  cautery,  161 
Ganglion,  Meckel's,  131 
Ganglionic  cells,  8 
Gasserian  ganglion,  193 
General  examination  of  the  eye,  19 
considerations  of  treatment,  41 
survey  of  the  eye,  20 
Gerontoxon  (arcus  senilis)  258 
Gland,  lachrymal,  151 

diseases  of,  152 
extirpation  of,  153 
meibomian,  168 
Glass,  crown,  68 

pebble,  68 
Glasses,  for  aphakial  eyes,  369 
colored,  70 
concave,  69 
cylindrical,  70 
decentred,  115 
of  double  focus,  92 
protective,  70 
spherical,  69 
stenopaic,  70 
pantoscopic,  92 
Glaucoma,  24,  359 
absolute,  365 
acute  inflammatory,  360 
causes,  360 
diagnosis,  360 
symptoms,  360 
treatment,  361 
chronic  non-inflammatory,  361 
causes,  362 


Glaucoma,  diagnosis,  364 

consecutive,  360 

eserine  in,  361 

excavation  of  nerve  in,  364 

fulminans,  361 

hemorrhagic  form  of,  3,  170 

iridectomy  in,  369 

maligna,  370 

medical  treatment  of,  369 

myotomy  in,  370 

nature  of,  363 

neuralgic  pain  in,  364 

operations  for,  370 

ophthalmoscopic  diagnosis  of,  365 

premonitory  symptoms,  362 

prognosis  in,  371 

sclerotomy  in,  370 

secondary,  360 

simplex,  361 

subacute,  361 

symptoms,  362 

treatment,  368 

varieties,  359 
Glioma  of  retina,  390 
Glio-sarcoma  of  retina,  390 
Globe,  dislocation  of,  132 

foreign  bodies  within,  62 

suppurative  inflammation   of,  60 

tension  of,  to  determine,  23 

inflammation  of  the  whole,  132 
Glycerine,  156 
Goitre,  exophthalmic,  140 
Gonorrhceal  ophthalmia,  214 

iritis,  271 
Gouge,  55 

Gouty  diathesis  in  iritis,  271 
Graefe,  von.  Prof.,  205 

compress  bandages  for  the  eye,  42 

operation  for   linear  extraction, 
330 

operation  for  ectropium,  188 
Granules  of  retina,  8,  373 
Granular  conjunctivitis  219 

lids,  219 

ophthalmia,  219 
Granulations,  acute,  221 

chronic,  221 

vesicular,  226 

hard,  220 

soft,  226 
Graves'  disease,  140 
Green's  test  cards,  90 
Groove,  lachrymal,  130 
Gruening's  magnet,  62 
Gunshot  wounds,  51 
Gunpowder,  52,  63 

HALOS,  367 

Hard  cataract,  332 

Hardness  of  globe  {vide  Tension) 

Hay  fever,  205 


416 


INDEX. 


Headache,  asthenopic,  95,  114 
Helmholtz,  29 

ophthalmoscope  of,  30 
Hemeralopia,  388 

in  retinitis  pigmentosa,  383 
Hemiopia,  24,  388 

equilateral,  389 

homonymous,  389 

temporal,  389 
Hemorrhage  into   anterior   chamber, 
58 

from  choroid,  63 

into  conjunctiva,  198 

into  orbit,  51 

into  optic  nerve  sheath,  376 

into  retina,  376 

into  vitreous,  61, 346 

a  cause  of  amaurosis,  402 
Herpes  of  the  conjunctiva,  227 

of  the  cornea,  238 

frontalis,  193 

zoster  ophthalmicus,  193 
Hexagonal  pigment  cells  of  retina,  6, 

8,374 
Hippus,  285 

Hieronymous  diplopia,  106 
Holmgren's  test,  24 
Homatropine,  47,  98 

hydrobromate  of,  45 
solution  of,  47 
Homonymous  diplopia,  105 
Hops,  decoction  of,  45 
Hordeolum,  172 
Hot  applications,  45 
Hotz's  operation  for  trichiasis,  184 
Hutchinson's  teeth,  250 
Humors  of  eye,  4 
Hyalitis,  342 
Hyaloid  artery,  persistent,  846 

body,  341 

diseases  of,  342 

canal,  341 

fossa,  341 

membrane,  4,  8,  341 
Hyaloidea,  4,  341 
Hydatids  in  orbit,  142 
Hydrocephalus,  133 
Hydrophthalmus,  266 
Hydrops  nervi  optici,  398 
Hyoscyamine,  46 

Hypaemia  (blood   in  anterior   cham- 
ber), 58 
Hypersemia  of  conjunctiva,  199 

of  choroid,  360 

of  iris  270 

of  optic  nerve,  396 

of  retina,  375 
Hyperaesthesia  of  the  cornea,  239 

retina,  386 
Hypermetropia,  75,  76 

absolute,  80 


Hypermetropia,  acquired,  76 

asthenopia  in,  77 

divergence  of  visual  axes  in,  104 

diagnosis  of,  76,  78 

facultative,  80 

a  frequent  cause  of  asthenopia, 
77 
of  convergent  squint,  119 

latent,  79 

manifest,  79 

ophthalmoscopic  diagnosis  of,  78 

original,  76 

relative,  80 

symptoms,  77 

treatment  of,  81 
Hypermetropic  eye,  81 
Hypermature  cataract,  324 
Hyperopia  (tide  Hypermetropia.) 
Hyperopic  astigmatism,  94 
Hypopyon,  245,  253 
Hysterical  amblyopia,  403 

hyperaesthesia  of  the  retina,  386 

ICE  bag,  44 
Ice,  use  of,  44  . 
Ideas  of  solidity,  17 
lUnmination,  focal,  28 

oblique,  28 
Images,  actual,  of  fundus  oculi,  36 

virtual,  of  fundus  oculi,  34 
Immature  cataract,  324 
Incipient  cataract,  324 
Inferior  oblique  muscles,  9 
paralysis  of,  110 

recti  muscles,  9 

paralysis  of,  109 
Infinite  distance  defined,  64 
Inflammation  of  choroid,  349 

ciliary  body,  293 

conjunctiva,  200 

cornea,  238 

eyelids,  169 

globe,  suppurative,  60,  356 

iris,  270 

and  choroid, 

and  ciliary  body,  294 

lachrymal  gland,  152 

sac,  162  ? 

optic  nerve,  397  f 

orbit,  cellular  tissue  of,  133  ' 

retina,  378 

sclerotic,  264 

vitreous  humor,  342 

■whole  eye,  355 
Infra-orbital  groove,  130 
Injection  of  ciliary  vessels,  23 

of  ciliary  zone,  23 
Injuries  of  the  eye,  50 

of  the  ciliary  region,  295 

conjunctiva,  52 

cornea,  54 


INDEX. 


417 


Injuries  of  the  globe  from  gunpow- 
der, 53 

iris,  59 

lachrymal  apparatus,  52 

lens,  59 

lids,  49 

orbit,  50 

retina,  63 

sclerotic,  57 

sympathetic     ophthalmia     from, 
303 

vitreous,  61 
Inoculation  for  pannus,  226 

granulated  lids,  225 
Insects,  bite  of,  169 
Instruments,  47 

Beer's  knife,  49 

fixation  forceps,  49 

foreign-body  hook,  62 

iris  forceps,  286 

gouge,  55 

ins  scissors,  289 

keratome,  286 

lid  elevators,  47 

linear  cataract  knife,  286 

scoop,  335 

specula,  48 

spud,  55 

wire  scoop,  336 
Insufficiency  of  recti  externi,  113 

recti  interni,  113 
Internal  rectus  muscle,  9 

insufficiency  of,  113 

paralysis  of,  109 

tenotomy  of,  123 

weakness  of,  113 

treatment  of,  114 
Inter-cerebral  fibres.  394 
Inter-retinal  fibres,  394 
Inter-vaginal  space,  9,  394 
Intra-cranial  disease,  397 
Intra-ocular  tension,  6 

tumors.  282,  356,  390 
Inversion  of  lid,  183 
Inverted  image,  36 
Investing  membranes,  4 
Involuntary  oscillations  of  globe,  129 
Iridectomy,  61,  286 

in  cataract,  334 

in  conical  cornea,  260 

in  corneal  opacities,  285 

in  glaucoma,  369 

in  iritis,  276 

indications   for   performance  of, 
285 

in  lamellar  cataract,  320 
Irideremia,  282 
Irido-choroiditis,  351 

sympathetic,  59 

treatment,  351 
Irido-cyclitis,  294 


Iridodesis,  290 

mode  of  performing,  290 
Iridodialysis,  290 
Iridotomy,  289 
Iris,  4,  7 

absence  of,  congenital,  282 

adhesions  of,  272 

anatomy  of,  7,  268 

angle  of,  12 

cancer  of,  282 

coloboma  of,  282 

color  of,  22 

congenital  malformations,  282 

contraction  of,  284 

cysts  of,  282 

detachment  of,  58 

dilatation  of,  283 

diseases  of,  270 

to  examine,  22 

foreign  bodies  in,  58 

functional  troubles  of,  283 

hernia  of,  56,  244 

hyperaemia  of,  270 

inflammation  of,  270 

injuries  of,  57, 

ligamentum  pectinatum  of,  237 

movements  of,  269 

muscles  of,  269 

operations  on  the,  285 

prolapse  of,  56,  244 

tremulous,  59 

tumors  of,  282 

wounds  of,  57 
Irish  race,  221 
Iritis,  acute,  270 

causes  of,  271 

chronic,  274 

gonorrhceal,  271 

idiopathic,  simple,  270 

parenchymatous,  280 

plastic,  280 

serous,  278 

spongy,  282 

suppurative,  281  , 

sympathetic,  302  j 

syphilitic,  271 

traumatic,  271 

treatment  of,  274 
Ischsemia  retinae,  375 
Iwanoff,  78 

on  ciliary  muscle,  78 

JAEGER,  test  types  of,  88 
Jequirity,  225 

Jones,  Wharton,  operation  for  ectro* 
pium,  187 

KERATITIS,  238 
diffusa,  249 
fascicularis,  239 
interstitial,  249 


418 


INDEX. 


Keratitis,  neuro-paralytic,  266 

parenchymatous,  249 

phlyctenularis,  238 

punctata,  256 

pustulosa,  235 

suppurativa,  253 

ulcerosa,  242 

vasculosa,  252 
Keratocele,  247 
Kerato-cornus,  269 
Kerato-globus,  261 
Kerato-iritis,  242 
Keratoscopy,  39,  89 
Knapp's  clamp  forceps,  174 

foreign-body  hook,  62 

knife,  158 

plastic  lid  operation,  189 
Knife,  Agnew's,  168 

Beer's,  49 

Knapp's,  158 

Noyes',  158 

Stilling's,  158 
Kuhne,  investigations  of  visual  purple, 
17 

LACERATION  of  conjunctiva,  62 
of  choroid,  63 
of  lids,  51 
Lachrymal  abscess,  l62 
apparatus,  150 

anatomy  of,  150 

diseases  of,  150 

injuries  of,  62 
canal,  151 

obstruction  of,  156 

stricture  of,  156 
canaliculus,  151 

slitting  the,  154 
caruncle,  150 
duct,  2 
fistula,  162 
gland,  2,  150 

accessory,  152 

diseases  of,  152 

extirpation  of,  153 

fistula  of,  152 

functional  diseases  of,  153 

hypertrophy  of,  152 

inferior,  150 

inflammation  of,  152 

tumor  of,  153 
groove,  130 
punctum,  2,  151,  167 

eversion  of,  154 

mal-position  of,  164 

occlusion  of,  154 

obliteration  of,  154 
papilla,  167 
probes,  159,  161 
sac,  151 

abscess  of,  162,  164 


Lachrymal  sac,  degeneration  of,  164 
blennorrhoea  of,  164 
extirpation  of,  161 
fistula  of,  162,  164 
inflammation  of,  162 
obliteration  of,  161 

stricture,  154,  158 
causes,  156 

Stilling's  operation  for,  158 
symptoms,  156 

syringe,  161 
Lachrymation,  153 

varieties,  156 

treatment,  156 

electrolysis  in,  160 
Lacus  lachrymalis,  150 
Lagophthalmos,  191 
Lamina  cribrosa,  5, 13,  394 

fusca,  13,  263 
Laminated  cataract,  319 

cells  of  retina,  8 
Lateral  dislocation  of  lens,  340 

illumination,  28 
Layer  of  rods  and  cones,  8,  373 
Lead  amblyopia,  403 

deposits  on  cornea,  258 

a  cause  of  nerve  atrophy,  401 
LeBrun's  operation  for  cataract,  337 
Lens,  4,  16 

crystalline,  anatomy  of,  311 

absence  of,  340 

diseases  of,  313 

dislocation  of,  59,  60,  340 

focal  length  of,  65 

foreign  bodies  in,  60 

injuries  of,  59 

operations   upon,    316,    318, 
330 

physiological  changes  in,  72 

wounds  of,  60 
Lenses,  optical  properties  of,  64,  65 

concave,  65,  69 

convex,  64,  69 

cylindrical,  69 

forms  of,  70 

kinds  of,  68 

prismatic,  70 

spherical,  69 

stenopaic,  70 
Lenticular  cataract,  315 
Leptothrix,  155 
Leucomata,  257 
Leucoma  adherens,  247.  257 

totalis,  257 
Leucorrhoea,  210 
Levator  palpebrae,  9,  167 

paralysis  of,  190 
Lice  on  eyelashes,  175 
Lid  elevators,  47 
Lids  {vide  Eyelids) 
Liebold's  syringe,  45 


INDEX. 


419 


Liebold  on  nse  of  mere,  nit.,  229 
Ligament,  suspensory,  7,  16 
Ligamentum  pectinatum,  12,  237 
Limbus  conjunctivae,  197 
Limiting  membrane,  6 
Lime,  burns  by,  53 

treatment  of,  53 
Lime  water  and  oil,  52 
Linear  extraction  of  cataract,  318 
Lipomata,  142 
Liebreich's  operation  for  cataract,  337 

opththalmoscope,  31 
Light  streak  on  retinal  vessels,  38 
Listing,  diagrammatic  eye  of,  14 
Locomotor  ataxy,  a   cause   of    optic 

nerve  atrophy.  401 
Long  ciliary  arteries,  10 

nerves,  9,  10 
Long  sightedness  {vide  Hypermetro- 
pic) 
Loring,  29,  31 

on  relation  of  axis  to  degree  of 
myopia,  8 
Loring's  ophthalmoscope,  32 
Lotions,  disinfecting,  45 
Lupoid  growths  on  lids,  193 
Lupus  of  conjunctiva,  234 

of  lids,  193 
Lymph  space,  0,  9,  13 

of  optic  nerve,  13, 394 
Lymphatics,  11 

of  eyeball,  12 
Lymphoid  infiltration  of  conjunctiva, 
226 


MACULA  of  the  cornea,  257 
Macula  lutea,  8, 17,  24 

ophthalmic  appearance  of,  39,  375 

to  examine,  38 
Madarosis,  175 
Magnet,  Gruening's,  63 
Malignant  glaucoma,  370 

pustule  of  eyelids,  171 

tumor  of  orbit,  142 
Malposition  of  lids,  183,  186 
Mariotte,  blind  spot  of,  17,  389 
Mariotte's  experiment,  17 
Mature  cataract,  324 
Measles,  122,  202,  239 
Measure,  linear,  of  squint,  121 
Meckel's  ganglion,  131 
Medicine  dropper,  46 
Medullary  carcinoma  of  choroid,  356 

of  orbit,  142 
Megalophthalmos    [vide    Hydropthal- 

mus) 
Megalopsia,  353 
Meibomian  cysts,  173 

glands,  168 

anatomy  of,  16 


Meibomian  gIands,inflammation  of  ,173 

calcareous  deposits  in,  231 
Melanoma  of  cornea,  261 

of  orbit,  356 
Melanotic  cancer  of  choroid,  356 

of  orbit,  142 
Membrana  chorio-capillaris,  348 

hyaloidea,  8,  341 

limitans,  6,  373 

nictitans,  196 
Membrane,  posterior  elastic,  5 

anterior  elastic,  235  j 

of  Descemet,  12,  235,  237         j 

hyaloid,  8  | 

limiting,  6 
Membranous  cataract,  339 
Meningitis,  133 

a  cause  of  muscular  paralysis,  108 

cerebro-spinal,  a  cause  of  panoph- 
thalmitis, 355 
Meniscus,  negative,  69 

positive,  69 
Menses,   suppression   of,   a   cause   of 

capsulitis,  139 
Mercury,  ointments  of,  176 
Meridians  of  eye,  4 

horizontal,  4 

principal,  4 

vertical,  4 
Metamorphopsia,  88,  353 
Methods  of  examination,  19 
Micropsia,  353 
Miliary  trachoma,  226 
Military  ophthalmia,  220 
Milium,  194 
Milky  cataract,  315 
Mixed  astigmatism,  94 

cataract,  321 
\  Mobility  of  the  eye,  to  examine.  20 
Moles  on  the  lids,  194 
MoUuscum,  194 
Monocular  polyopia,  93 
Morgagnian  cataract,  324 
Mortar,  injuries  from,  53 

treatment,  53 
Mucocele,  156,  164  : 

Muscae  volitantes,  87,  343 
Muscles  of  the  eye,  9 

anatomy  of,  101 
action  of,  102 
affections  of,  101 

conjugate,  104 
Muscle  of  accommodation,  7,  291 

annular  of  Mueller,  292 

ciUary,  7,  9,  291 
diseases  of,  295 

tendo  oculi,  151 

tensor  taris,  151 

rectus  externus,  9,  101 

paralysis  of,  110 
inferior,  9,  101 


420 


INDEX. 


Mnscles  of  the  eye,  paralysis  of,  109 
rectus  internus,  9,  101 

paralysis  of,  109 
superior,  9,  101 

paralysis  of,  109 
inferior  oblique,  9,  101 

paralysis  of,  110 
superior  oblique,  9, 101 

paralysis  of,  9,  101 
ring,  7 

orbicularis  palpebrarum,  3,  168 
spasm  of,  192 
j         sphincter  of  ciliary  body,  7 
I  of  iris,  9 

testing  strength  of,  192 
extrinsic,  101 
intrinsic,  101 
internal,  101 
external,  101 
yoked,  104 
Muscular  asthenopia,  77,  92,  113 
causes,  114 
Bymptoms,  114 
diagnosis,  115 
test,  115 
treatment,  115 
insufficiency,  113 
paresis,  113 
paralysis,  107 
causes,  108 
symptoms,  108 
diagnosis,  109 
treatment,  111 
Mydriatics,  45 
atropine,  46 
duboisia,  46 
homatropine,  46 
Mydriasis,  283 
Myopia,  83 
causes,  84 

convergence  of  visual  axes  in,  104 
diagnosis,  88 

length  of  optic  axis  in,  85 
pathological  changes  in,  86 
prognosis  in,  92 
relation  of  axis  to  degree  of,  85 
treatment  of,  89 
simulated,  81 
symptoms,  88 
Myopic  eye,  90 

astigmatism,  97 
crescent,  87 

eye,  pathological  changes  in,  86 
Myosis,  284 
Myotics,  45 
eserine,  47 
pilocarpine,  47 


N^VUS  of  lids,  194 
Narcotics,  use  of,  193 


Nasal   catarrh  in  lachrymal  trouble, 

165 
Nasal  duct,  151 

exploration  of,  157 

stricture  of,  156 
treatment,  158 
Near  point,  71,  73 
Near-sightedness  {vide  Myopia) 
Nebulae  of  cornea,  257 
Necrosis  of  orbit,  139 
Negative  accommodation,  72 
Negroes,  221 
Nephritic  retinitis,  380 
Nerves  of  eye,  9 

fifth,  ophthalmic  division  of,  9 

fourth,  9 

long  ciliary,  10  -j 

optic,  9 

atrophy  of,  24 

sixth,  9 

third,  9,  10 

paralysis  of,  110 
Neuralgia  ciliaris,  272 
Neuritis,  95 
Neuritis  optica,  397 

descendens,  398 
Neuro-paralytic   affection  of   cornea, 

256 
Neuro-retinitis,  378 

diagnosis  of,  378 
Neurosis,  sympathetic,  302 

ef  fifth  nerve,  363 
Nictitation,  192 
Night-blindness,  388 
Nitrate  of  silver,  174 
Nodal  point,  66 
Node,  syphilitic,  145 
Nomenclature  of  glasses,  67 
Normal  eye,  defects  of,  16 
Noyes'    operation    for    canthoplasty, 
186 

speculum,  47 

knife,  158 
Nuclear  cataract,  322 
Nyctalopia,  388 
Nystagmus,  129 

OBJECTIVE  examination  of  the  eye, 

20 
Oblique  illumination,  28 
muscles,  102 

functions  of,  102 
Obliteration  of  lachrymal  sac,  Ifl 

of  pupils,  280 
Obstruction   of    lachryi*Bl   passages, 

156 
Occipital  lobes,  8 
Occlusion  of  pupil,  280 
Ocular  sheath,  2,  13, 101,  132 
inflammation  of.  139 
muscles,  paralysis  of,  107 


INDEX. 


421 


Ocular  muscles,  paralysis  of,  causes, 
108 
symptoms,  108 
Oculo-orbital  fascia,  168 
<Edema  of  conjunctiva,  198 

of  eyelids,  169 

of  retina,  375,  376 
Oil,  linseed,  and  lime  water,  52 

sweet,  in  burns,  53 
Ointments, 

grapho-cosmoline,  176 

mercurial,  red  oxide,  176 

white  precipitate,  176,  178 
yellow  oxide,  176,  178 
Onyx,  253 
Opacities  of  cornea,  257 

of  lens,  38,  313 

of  optic  nerve  fibres,  38 

of  vitreous,  343 
Opaque  optic  nerve  fibres,  375 
Ophthalmia,  catarrhal,  201 

croupous,  217 

diphtheritic,  218 

Egyptian,  220 

gonorrhoea!,  214 

granular,  220 

herpetic,  227 

membranous,  217 

military,  220 

neonatorum,  200,  208,  209 

neuro-paralytic,  256 

phlyctenular,  227 

purulent,  206 

pustular,  227 

scrofulous,  227 

sympathetic,  301 

tarsi,  174 
Ophthalmoscope,  appearance  of   fun- 
dus with,  39 

description  of,  31 

examination  with,  34 
direct  method,  34 
indirect  method,  35 

how  to  use,  34 

to   detect   foreign  bodies,  62 

liinds  of,  31 

inverted  image  with,  36 

of  Helmholtz,  30 

of  Liebreich,  31 

of  Rekoss,  31 

principle  of,  30 

virtual  erect  image  with,  34 

real  inverted  image  with,  36 

Knapp's,  31,  32 

Loring's,  31 

Wecker's  refraction,  31 

double  disk,  Knapp's,  32 

single  disk,  Knapp's.  33 
Ophthalmoscopic  appearances  of  nor- 
mal fundus,  37 
Optical  centre,  66 


Optici  thalami,  8 

Optic  axes,  convergence  of,  in  accom-> 
modation,  28 
axis,  3 

length  of,  65 
chiasma,  8,  392 
disc,  9,  37,  395 

how  to  find,  36 
normal  ophthalmoscopic  ap- 
pearance of,  37,  395 
oval  appearance  of,  96 
foramen,  9,  131 
nerve,  8,  9 

anatomy  of,  8 

atrophy  of,  24,  134,  144,  400 
cupping  in,  401 
interstitial,  401 
parenchymatous,  401 
primary,  400,  401 
secondary,  400,  401 
in  amaurosis,  404 
cerebral,  401 
amblyopia,  403 

from  alcohol,  403 
from  tobacco,  403 
cupping  of,  395 
diseases  of,  396 
entrance,  10,  394 
excavation  of,  395 
congenital,  393 
in  atrophy,  401 
glaucomatous,  364 
physiological,  395 
fibres,  opaque,  375 
hyperaemia  of,  396 
inflammation  of,  397 
pigmentation  of,  396,  401 
roots  of,  8 
tumors  of,  405, 
neuritis,  144,  397 
ascending,  398 
descending,  398 
retro-bulbar,  399 
papilla,  9,  393 
sheath,  10,  394 
tracts,  8,  393 
Optico-ciliary  neurectomy,  307 

neurotomy,  307 
Orbicularis  palpebrarum,  168 
paralysis  of,  191 
spasm  of,  192 
Orbit,  abscess  of,  133,  136 
anatomy  of,  130 
aneurism  of,  147 
caries  of,  132,  139 
cysticerci  in,  142 
cellulitis  of,  133,  136 
diseases  of,  130,  132 
diseases  of  blood-vessels,  147 
diseases  of  cavities  surrounding, 
148 


422 


INDEX. 


Orbit,  echinococci  in,  142 

exostosis  of,  144 

extirpation  of  contents,  146 

exophthalmns,  pulsating,  147 

fractures  of,  50 

foreign  bodies  in,  50 

hemorrhage  into,  60 

hydatids  in,  142 

inflammation  of  cellular  tissue  of, 

133 
injuries  of,  50 
'  necrosis  of,  132,  139 

periostitis  of,  132,  136 
pressure  upon,  from  neighboring 

cavities,  148 
wounds  of,  50 
tumors  of,  132,  142 
angiomata,  142 
bony,  144 
cancers  of,  145 

cartilaginous,  144 
medullary,  144 
melanotic,  144 
scirrhus,  145 
cystic,  142,  144 
diagnosis  of,  143 
fatty,  142 
fibromata,  142 
fibrous,  142,  144 
glio-sarcoma,  144 
hydatids,  142 
lipomata,  142 
osseous,  142, 144 
osteomata,  142 
sarcomatous,  142,  144 
treatment  of,  145 
vascular,  145 
Orbital  abscess,  51 
cellulitis,  51,  133 
periostitis,  136 
Ora  serrata,  8,  372 
Oscillation  of  eyeballs,  129 
Ossification  of  the  choroid,  303 
Osteomata,  142 
Ozsena,  165 

PAIN,  characteristic,  22 

as  aid  to  diagnosis,  22 
Palpebrse,  167 
Palpebral  conjunctivitis,  199 

fissure,  167 

folds,  196 

ligaments,  167 

muscle,  168 
Pannus,  225,  239 

crassus,  222 

from  granulations,  222 

herpeticus,  241 

sicca,  222 
Panophthalmitis,  132,  134,  355 

treatment,  355 


Pantoscopic  glasses,  92 

spectacles,  92 
Papilla,  optic,  9,  393 

lachrymalis,  167 
Papillary  hypertrophy,  207,  209 

trachoma,  220 
Papillitis,  398 
Paracentesis  of  cornea,  217,  245 

corneas,  245 
Paralysis  of  accommodation,  295 

of  ciliary  muscle,  295 

of  fourth  nerve,  110 

of   levator   palpebrae    superioris 
190 

of  ocular  muscles,  107 

of  orbicularis  palpebrarum,  191 

of  portio  dura  of   seventh  nerve, 
191 

of  sixth  nerve,  110 

of  third  nerve,  110 
Parenchymatous  keratitis,  249 
Paresis  of  accommodation,  297 

of  ocular  muscles,  113 
Penetrating  wounds  of  globe,  62 
Percipient  elements,  8 
Perforation  of  cornea,  244 

of  lachrymal  sac,  152 
Peri-choroidal  space,  12 
Perimeter,  25 
Periodical  squint,  118 
Periorbita,  131 
Periostitis  of  orbit,  136 
Peripheral  vision,  25 
Periscopic  spectacles,  69 
Periotomy,  225 

Permanent  strabismus,  119,  127 
Petit's  canal,  312 

Phlegmonous    inflammation    of   eye- 
lids, 169 
Phlyctenular  conjunctivitis,  227 

keratitis,  238 
Phosphenes,  375 
Photophobia  in  conjunctivitis,  202 

in  iritis,  272 

in  retinal  hyperaesthesia,  386 

in  scrofulous  ophthalmia.  227 
Phtheiriasis  ciliarum,  175 
Phthisis,  141 
Physiological    excavation     of     optic 

nerve,  395 
Physiology  of  the  eye,  13 
Pia  mater,  9 
Pial  sheath,  9,  394 
Pigment  cells,  6 

hexagonal  of  iris,  7 
Pigment  degeneration   of  retina,  383 

layer  of  retina,  8,  374 

deposits  in  the  conjunctiva,  234 
Pilocarpine,  47 

hydrobromate  of,  47 
Pinguecula,  233 


INDEX. 


423 


Plastic  iritis,  280 

operations,  185, 189 
Plica  semilunaris,  196 
Point,  near,  71 

far,  71 
Poles  of  the  eye,  3,  9, 
Polyopia,  monocular,  93 
Polypi  of  caruncle,  231 

of  conjunctiva,  233 
Porus  opticus,  395 
Posterior  chamber,  4,  12 

ciliary  arteries,  10 
nerves,  10 

elastic  lamina,  235 

focus,  principal,  15 

polar  cataract,  338 

pole,  3,  9 

sclerotico-choroiditis,  87,  356 

staphyloma,  87,  356 
Poultices,  45 

of  Phytolacca  root,  136 
Pray's  test  cards,  96 
Presbyopia,  72 

cause,  72 

diagnosis,  73 

symptoms,  73 

treatment,  73 
Pressure  bandage,  42 

intra-ocular,  6,  23 
Primary  deviation,  104 
Prismatic  spectacles,  112 
Prisms,  action  of,  70 

for  double  vision,  112 

for  testing   strength   of  muscles, 
115 

in  muscular  asthenopia,  115,  116 
Probing  nasal  duct,  157 
Processes,  ciliary,  6 
Probes,  canaliculus,  Anel's,  154 

lachrymal,  159 

Bowman's,  159 
Theobold's,  159 
Weber's  159 
Williams',  159 

lead  wire,  161 
Prolapse  of  iris,  56,  244,  247 
Prominence  of  the  eyeball,  20 
Protective  glasses,  44 
Prothesis  oculi,  309 
Protrusion  of  globe.  20 
Prout's  clamp  forceps,  174 
Pterygium,  231 
Ptosis,  110, 190 
Puerperal  fever,  133 
Pulsation  of  retinal  vessels,  362 
Pulsating  exophthalmus,  147 
Punctum  lachrymalis,  2,  167 

eversion  of,  154 

malposition  of,  154 

obliteration  of,  154 

obstruction  of,  154 


Punctum  proximum,  71 

remotum,  71 
Punctured  wounds,  51 
Pupil,  7,  29 

artificial,  operations  for,  285 
by  corelysis,  290 
by  incision,  289 
by  iridectomy,  285 
by  iridodesis,  290 
by  iridodialysis,  290 
adhesion  of,  272 
action  of  atropine  on,  46 
duboisia,  46 
eserine,  47 
homatropine,  47 
pilocarpine,  47 
contraction  of,  abnormal,  284 

artificial,  46 
closure,  280 
dilatation  of,  abnormal,  283 

artificial,  46 
distortion  of,  59 
eccentric,  283 
exclusion  of,  273 
movements  of,  268 
occlusion  of,  273,  280 
Pupillary  membrane,  persistence   of, 

283 
Purple,  visual,  8,  17 
Purulent  ophthalmia,  206 

conjunctivitis,  206 
Pustular  ophthalmia,  227 

conjunctivitis,  227 
Pustule,  malignant,  of  eyelid,  171 
Pyajmia,  133 

QUALITATIVE  perception  of  light,  27 
Quantitative  perception  of  light,  27 
Quartz,  transparent,   used  for  lenses, 

68 
Quinine  amblyopia,  403 

RABBIT,  grafting  conjunctiva  of,  233 
Radical  fibres  of  optic  nerve,  8 
Range  of  accommodation,  27,  71 

absolute,  72 

binocular,  119 

relative,  28,  72 

negative,  72 

positive,  72 
Readjustment,  operation  of,  128 
Reclination  of  cataract,  330 
Recti  muscles,  102 

functions  of,  102 

origin  of,  102 

insertion  of,  102 

insufficiency  of,  114 
Rectus  muscle,  paralysis  of  external, 
110 
of  inferior,  109 
of  internal,  109 


424 


INDEX. 


Rectus  muscle,  paralysis  of  superior, 

109 
Red  color,  field  of  vision  for,  26 

scotoma  for,  403 
Reduced  eye,  Listing's,  14 , 
Refraction,  64 
Refraction  of  eye,  64 

errors  of,  64 

in  astigmatism,  93 

in  hypermetropia,  76 

in  myopia,  83 

in  normal  vision,  66 

differs  in  the  two  eyes,  99 
Refracting  media,  4 

ophthalmoscopic  examination  of, 
35 
Refractive  errors,  64 

correction  of,  67 

power  of  the  eye,  65 
Region  of  distinct  vision,  17 
Rekoss,  29 

Reposito  ciliarum,  181 
Retina,  4,  8 

anaemia  of,  375 

anaesthesia  of,  388 

anatomy  of,  8,  372 

atrophy  of,  401 

blood  supply,  8,  374 

cancer  of,  390 

central  artery  of,  8,  395 

detachment  of,  57,  63,  384 

diseases  of,  375 

embolism  of  central  artery,  376 

examination   of,   by    ophthalmo- 
scope, 38,374 

fibres  of,  8,  373 

ganglionic  cells  of,  8,  373 

glioma  of,  390 

hyperaemia  of,  375 

hyperaesthesia  of,  386 

inflammation  of,  378 

injuries  of,  63 

ischaemia  of,  375 

layers  of,  8,  372 

lymph  spaces  of,  13 

metamorphopsia,  88,  353 

ophthalmoscopic  appearances  of, 
374 

opthalmoscopic   examination   of, 
38,  374 

percipient  elements  of,  8,  373 

purple  of,  8 

thrombosis  of  central  artery,  376 

tumors  of,  390 
Retinal  purple,  8 
Retinitis,  378 

albuminurica,  380 

apoplectica,  378 

causes,  378 

central  recurrent,  382 

diagnosis  of,  378 


Retinitis,  idiopathic,  378 

leucaemic,  384 

nephritic,  380 

pigmentosa,  383 

proliferans,  384 

serous,  378 

symptoms,  378 

syphilitica,  382 

treatment,  379 
Retractors,  use  of,  21 
Retro-tarsal  folds,  196 
Retro-bulbar  neuritis,  399 
Rente,  29 

Rheumatic  iritis,  271 
Rheumatism,  a  cause  of  muscular  pa- 
ralysis, 108 
Ring,  muscle,  7 

scleral,  9,  37,  395 

tendinous,  7 

choroidal,  37,  395 
Rodent  ulcer  of  cornea,  244 
Rods  and  cones,  8,  373 
Rose  cold,  205 
Rose,  visual,  17 
Rotation,  centre  of,  2 
Rupture  of  the  choroid,  356 

sclerotic,  67 

SAC,  lachrymal,  anatomy,  151 

diseases  of,  162 

destruction  of,  161 

fistula  of,  162 

inflammation  of,  162 

stricture  of,  154,  158 
Saemish,  205 

operation,  246 
Sarcoma  of  choroid,  356 

of  conjunctiva,  234 

of  cornea,  261 

of  orbit,  144 
Scalping  operation,  181 
Scarlet  fever,  122,  239 
Scarlatina,  202 
Schlemm's  canal,  5,  7,  12 
Scirrhus  of  orbit,  145 
Sclera,  4 

anatomy,  262 

diseases  of,  263 

pathological  changes  of,  in  M,  86 

injuries  of,  57 

rupture  of,  57 

staphyloma,  anterior,  265 
posterior,  266 
Scleral  puncture    in   retinal   detach- 
ment, 385 
Scleral  ring,  9,  37 
Sclerectasia,  posterior,  266 
Scleritis,  264 

causes,  264 

symptoms,  264 

treatment,  265 


INDEX. 


425 


Solero-corneal  junction,  237 
Sclerotic  {vide  Sclera) 
Sclerotico-choroiditis     posterior,     87, 

356 
Sclerotomy  in  glaucoma,  370 
Scoop,  334 

Scoop  extraction,  337 
Scotoma,  17,  389 

central,  389 

negative,  389 

positive,  389 
"fecotomata,  389 
Scrofulous  ophthalmia,  227 
Sebaceous  cysts  of  eyelids,  173 
Secondary  cataract,  339 

deviation,  104 
Semilunar  folds,  196 
Senile  cataract,  322 
Seventh  nerve,  paralysis  of,  191 
Shades,  44 
Sheath,  ocular,  2,  13, 101,  132 

of  optic  nerve,  10,  394 
Shell,  used  in  spectacle  frames,  68 
Short  ciliary  arteries,  10 

ciliary  nerves,  10 
Short  sight  {vide  Myopia) 
Short-sightedness  {vide  Myopia) 
Siemen's  and  Halske's  cells,  160 
Simulated  blindness,  404 
Single  sight,  18 
Sinus,  cavernous,  11,  132 
thrombus  of,  147 

circular  venous,  5 

frontal  133,  148 
abscess  of,  148 
diseases  of,  133 
Sixth  nerve,  9 
Skin  grafting,  190 
Sliding  flap  operations,  189,  190 
Slippery-elm  poultices,  45 
Slit,  stenopaic,  96 
Slitting  up  of  punctum,  152 
Small-pox,  133,  202 
Smoke-colored  glasses,  70 
Snellen's  forceps,  174 

test  types,  26 

test  cards,  96       , 

reposito  ciliarum,  181 
Snow-blindness,  387 
Soda,  bicarbonate  of,  52,  176 
Sodae  biboratis  {vide  Borax) 
Soft  cataract,  315 
Solidity,  ideas  of,  17 
Solution  of  cataract,  317 
Solution  of  atropine,  46,  213 

aconite,  225 

boracic  acid,  45 

borax,  204 

carbolic  acid,  225 

duboisia,  45 

eserine,  47 


Solution  of  homatropine,  47, 

hydrastis,  225 

mere,  nit,  226 

nitrate  of  silver,  213,  216,  225 

pilocarpine,  47 

sanguinaria,  225 

sulphate  of  zinc,  203 

tannic  acid,  225 
Space,  arachnoidal,  9,  394 

inter-vaginal,  9,  394 

lymph,  6,  9,  13,  394 

Bub-arachnoidal,  87 

sub-dural,  394 

sub-vaginal,  394 

Bupra-choroidal,  347 

supra-vaginal,  13 

Tenon's,  6,  13 
Sparkling  synchysis,  344     • 
Spasm  of  accommodation,  299 

of  ciliary  muscle,  299 

of  eyelids,  192 

of  ocular  muscles,  129 

of  orbicularis  palpebrarum,  192 
Spasmodic  entropium,  183 
Spatula,  horn,  181 
Specks,  floating,  344 

in  vitreous,  343  « 
Spectacles,  67 

cataract,  339 

colored,  344 

cylindrical,  69 

decentred,  116 

kinds  of,  97 

protective,  44 

pantoscopic,  69 

periscopic,  69 

prismatic,  112,  115 

spherical,  69 

stenopaic,  70 

in  different  refraction  of  the  two 
eyes,  100 
Speculum,  47 

how  to  introduce,  48 

Liebold's,  48 

Noyes',  48 

spring,  48 

wire,  48 
Spherical  aberration,  16 
Sphincter  iridis,  7,  9,  269 

muscle  of  iris,  7,  9,  269 
of  ciliary  body,  7,  291 
Spinal  cord,  injuries  of,  a  cause  of 

amaurosis,  402 
Spongy  iritis,  282 
Spud,  53,  55 
Spurious  cataract,  314 
Squint  {Vide  Strabismus) 
Staphyloma,  anterior  sclerotic,  265 

cicatricial,  259 

of  cornea,  259 

operations  for,  259,  266 


426 


INDEX. 


Staphyloma,  posterior,  266 
Statistics  of  optical  defects,  76 

of  hyperopia,  76 
Stauung's papilla   (Fide Choked  Disc) 
Stenopaic  glasses,  70 

sUt,  96 

spectacles,  70 
Stillicidium  lachrymarum,  153 
StiUing's  knife,  168 

operation,  158 
Strabismometer,  120 
Strabismus,  105, 1 18 

alternate,  118 

apparent,  104 

atropine,  use  of,  in,  121 

causes,  100,  119,  126 

concomitant,  118 

confirmed,  119,  127 

convergent,  105,  118 

in  hypermetropia,  81 
in  myopia,  104 

deorsumvergent,  118,  128 

deviation,  primary,  120 
secondary,  109,  120 

diagnosis,  120 

divergent,  106, 118 
treatment  of,  127 
diagnosis,  127 
in  myopia,  126 

downward,  118 

external,  118 

internal,  118 

measurement  of,  120 

monolateral,  118 

operations  for,  123,  127, 128 

paralytic,  109 

periodic,  118 

permanent,  119,  127 

secondary,  109 

Bursumvergent,  118,  128 

treatment,  121,  123,  127 

upward,  118 
Streatfield's   operation    for  grooving 

the  tarsus,  185 
Stricture  of   lachrymal  passage,  154 
causes,  155 
treatment,  156 
Stye,  172 

Snb-arachnoidal  space,  87 
Sub-conjunctival  ecchymosis,  198 

tissue,  197 
Sub-dural  space,  394 
Sub-vaginal  space,  394 
Suction  operation  for  cataract,  319 
Superior  oblique  muscle,  9,  102 

rectus  muscle,  9,  102 
Suppurative  choroiditis,  355 

iritis,  281 

keratitis.  253 
Suppuration  in  vitreous,  342 
Sopra-choroidal  space,  347 


Supra-choroidea,  12,  347 
Supra-orbital    nerve,   division   of,  iu 
blepharospasm,  192 
notch,  130 
Supra-vaginal  space,  394 
Suspensory  ligament  of  iris,  268 

of  lens,  4,  7,  16 
Sweet  oil  in  burns,  53 
Symblepharon,  232 

operations  for,  233 
Sympathetic  iritis,  304 
irido-cyclitis,  304 
irritation,  301 
neurosis,  301 
ophthalmia,  301 
causes,  303 
diagnosis,  305 
symptoms,  303 
prognosis,  306 
treatment,  306 
when  to  operate,  306 
Sympathetic  serous  iritis,  304 

irido-choroiditis,  304 
Synchisis,  344 

scintillans,  344 
sparkling,  344 
Syndectomy  {vide  Periotomy) 
Synechia,  272 
annular,  272 
anterior,  247 
posterior,  272 
Syphilis,a  cause  of  muscular  paralysis, 
108 
diagnosis  of  congenital,  250 
Syphilitic  choroiditis,  356 
iritis,  280 
keratitis,  249 
retinitis,  382 
teeth,  250 

ulcers  of  conjunctiva,  234 
eyelids,  193 
Syringe  for  lachrymal  apparatus,  161 
Liebold's  sub-palpebral,  45 
suction,  for  removal  of  cataract, 
319 
Systems  of  enumeration  for  spectacle 
lenses,  68  " 

TANNIC  acid  and  glycerine,  161, 210 

Tar  water,  176 

Tarsal  cartilages,  168 

Tarsi,  168 

Tarso-orbital  fascia,  132,  168 

Tarsoraphy,  188 

Tarsus,  168 

Tattooing  the  cornea,  258 

needle,  258 
Teale's  operation   for   symblepharon, 

233 
Tear  passages,  151 

obstruction  of,  154 


INDEX. 


427 


Tears,  overflow  of,  153 

Teeth,  Hutchinson's,  250 

Telangiectasis  of  eyelids  {ncevi),  194 

Tendinous  ring,  7,  295 

Tendo  oculi,  151 

Tenon's  capsule,  2,  13,  101,  132 

inflammation  of,  132, 139 
space,  6, 13 
Tenonitis,  (inflammation  of  Tenon's 

capsule,)  139 
Tenotomy  for  strabismus,  122 

for  muscular  insufficiency,  116 
paralysis,  113 
Tension,  intra-ocular,  6,  23 
to  determine,  23 
in  glaucoma,  359 
increased,  358 

operations  for,  370 

by    division    of    ciliary 

muscle,  370 
by  iridectomy,  370 
by  paracentesis,  245 
relief  by  eserine,  359 
lessened,  57,  59 

in  intra-ocular  tumors,  357,  391 
symbols  to  indicate,  23,  24 
Tensor  choroidea,  291 

tarsi,  151 
Tent  drainage,  135 
Test  for  color,  24 
Test  cards,  96 

in  astigmatism,  97 
types,  26,  27 

to  determine  distant  vi8ion,27 
in  hypermetropia,  79,  82 
for  reading,  27 
in  myopia,  88 
Snellen's,  27 
Testing  acuteness  of  vision,  26 
Theobald's  probes,  159 
Third  eyelid,  196 
Third  nerve,  7,  9,  10, 
Thrombosis  of  central  artery  of  retina, 

376 
Thyroid  gland,  enlargement  of,  141 
Tinea  tarsi,  174 
I'obacco  amblyopia,  403 

a  cause  of  optic  nerve  atrophy, 
400 
Total  staphyloma  of  cornea,  259 
Torpor  of  retina,  388 
Trachoma,  215,  219 
Transactions  of  Am.  Horn.  Oph.  and 

Otol.  Soc,  160,  206 
Transplantation  of  cilia,  182 
of  conjunctiva,  233 
of  skin,  188,  189, 190 
Transverse  diameter  of  eyeball,  2 
Traumatic  cataract,  313 
cyclitis,  295 
iritis,  271 


Treatment,  general,  of  diseases  of  the 

eye,  41" 
Tremulous  iris,  285 
Trephining  the  cornea,  261 
Trichiasis,  180 

Truss  for  lachrymal  fistula,  163 
Tube,  drainage,  use  of,  135, 148 
Tubercles  of  the  choroid,  356 
Tumors  of  choroid,  356 

of  conjunctiva,  233 

of  cornea,  261 

of  eyelids,  194,  195 

of  iris,  282 

of  optic  nerve,  405 

of  orbit,  142 

of  retina,  390 
Tunica  vaginalis  bulbi,  101 
Tunics  of  eye,  4 
Twitching  of  eyelids,  192 
Tylosis,(thickening  of  lid  margin),  174 

ULCERATION  of  cornea,  242 
Ulcers  of  cornea,  213,  242 

syphilitic,  of  eyelids.  193 
Ulcus  comeae  serpens,  244 
Unit  of  numeration  of  lenses,  68 
metric,  68 
old,  68 
Uraemic  amblyopia,  402 
Upper  lid,  how  to  reverse,  21 
Upright  image,  ophthalmoscopic,  34 
Upward  squint,  118 
Use  of  the  eyes,  gymnastic,  116 

methodic,  116 
Uterine  diseases,  a  cause  of  muscular 

asthenopia,  114 
Uvea  {vide  Pigment  Layer  of  Retina) 
Uveal  tract  {vide  Choroid) 

VASCULAR  keratitis,  252 

supply  of  globe,  10 

supply  of  papilla,  372 

tumors  of  lids,  194 

zone,  23 
VaseUne,  53,  213,  226,  233 
Veins,  anterior  ciliary,  12 

of  ciliary  body,  11 

of  cornea,  11 

of  choroid,  11 

of  iris,  11 
Vense  vorticosa9,  6,  11,  13 
Venous  pulsation  of  retinal  vessels, 

sinus,  circular,  5 
Vernal  conjunctivitis,  205 
Vertical  diameter,  3 

meridian,  4,  93 
Vesicular  granulations,  226 
Vascularity  of  eyes  as  aid  to  diagno- 
sis, 23 
Vessels,  conjunctival,  197 

of  iris,  269 


428 


INDEX. 


'  Vessels,  retinal,  374 
sclerotic,  263 
subconjunctival,  264 
Yision,  peripheral,  25 
acuteness  of,  26 
double,  17, 104,  105 
eccentric,  25 
binocular,  18 
field  of,  25 

fixation  point  of,  25 
double,  18 
direct,  25 
central,  25 
tests  for,  26 
Tisual  acuity,  26 
angle,  66 
axis,  3 

length  of,  66 
centre.  3 
field,  25 

how  to  take,  25 

for  color,  26 

in  glaucoma,  365 

in  optic  nerve  atrophy,  401 

in  retinitis  pigmentosa,  383 
line,  3 
purple,  17 
rose,  17 
Titreous  humor,  4 
anatomy  of,  341 
cholesterine  in,  344 
cysticercus  in,  346 
degeneration  of,  57,  344 
diseases  of,  342 
floating  bodies  in,  344 
fluid  condition  of,  344 
foreign  bodies  im,  61 
hemorrhage  into,  61,  345 
inflammation  of,  342 
injuries  of,  61 

neoplastic  formations  in,  342 
opacities  of,  61,  344 
scotoma  in,  61,  344 


WANSTALL    on    spring   catarrh 

conjunctiva,  206 
Warm  applications,  44 


Warts  on  conjunctiva,  234 

on  eyelids,  194 
Watch  crystal,  used  as  eye-protector, 

217 
Watery  eye,  153 
Weakness  of  sight,  113 
Weber's  probes,  159 

canaliculus  knife,  154 

probe-pointed    lachrymal    knife, 
246 
Wecker's  clamp  strabismus  hook,  129 

scissors,  110 
Wharton  Jones'  operation  for  ectro- 

pium,  187 
Wounds  of  the  eye,  50 

ciliary  region,  295 

choroid,  63 

cornea,  54 

conjunctiva,  52 

eyeball,  60 

eyelids,  51 

gunshot,  51 

iris,  57 

lachrymal  apparatus,  52 

lens,  59 

orbit,  50 

retina,  63 

sclera,  57 

vitreous,  61 

sympathetic  inflammation  from, 
301 

XANTHELASMA,  194 
Xeroma  conjunctivae,  226 
Xerophthalmia,  226 
Xerosis,  223,  226 

YELLOW  spot,  17,  372 

appearance  of,  372,  376 
how  to  find,  375 
ointment,  228 


ZINN,  zonule  of,  4,  12,  16 
Zone,  ciliary,  264 
of       Zonule  of  Zinn,  4,  12,  16,  311 
Zinc  chloride,  147 
sulphate,  166 
iACKS^  .  .     ,    ... 
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